A Brief History of: The Tenerife Airport Disaster, a dark day for Aviation (Documentary)
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- เผยแพร่เมื่อ 3 ต.ค. 2024
- #Aircrashinvestigation #disaster
On 27 March, 1977, two Boeing 747 passenger jets, KLM Flight 4805 and Pan Am Flight 1736 respectively, collided on the runway at Los Rodeos Airport on the Spanish island of Tenerife.
Resulting in 583 fatalities, the Tenerife airport disaster is the deadliest in aviation history.
The Air crash investigation would discover a multitude of failures all of which led to the fateful accident.
Heres another couple of videos on the subject by two other great youtubers:
Qxir: • Worst Air Disaster in ...
Fascinating Horror: • The Tenerife Airport D...
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Want to see more aviation disasters let me know in the comments 👇
I mean... No? But I'd like to see more videos about the ones that have happened...
@@SlocketSeven Yeah, he could have worded that better.
There is a disaster I'd like to be seen covered. American Airlines Flight 191.
Please don't edit this comment to reword it, it got a chuckle from me.
Somethink about Polish Airlines Flight 5055 or Polish Airlines Flight 7.
It's OK with me, but also remember that there are others that make great videos on this theme. Mentour Pilot is very good at explaining the background and technical details, so you must keep up a good performance. No critique, bust a gentle advice.
There was a woman from the KLM plane who got off the plane at Tenerife and stayed there because her boyfriend lived there. Talk about lucky. Sadly her 2 friends got back on the KLM even though she asked them to stay with her.
I bet she regrets they didn’t, and I bet she was horrified at how close she came to death
@@melatoninqueen6914 How much would you like to bet the poor woman is suffering survivor's guilt?
@@DaWrecka 100% she would've, she heard that her friends died along with 500+ other people all because she decided to stay off the aircraft and go to her hour which was on the island. I can't imagine how much guilt she has over this knowing that because you decided to stay you got to live
@N Fels An interesting example of fate.
@@thepodcastcrew1113 they didn't die because she stayed off the aircraft. How insensitive.
This incident really is the “worst case scenario”
@Egon Freeman The perfect storm then
One minor linguistic point, Van Zanten’s “oh, yes” on being questioned by the Flight Engineer as to whether the Pan Am was clear of the runway was actually the word “jawel”. This is a contradictory form of yes in Dutch, implying that he was dismissing his colleague’s concern and that there was no thought in his mind that the runway was not clear.
I’m delighted to see that PD didn’t fall into the trap of discussing whether the Pan Am flight was at fault for taking the “fourth”exit from the runway rather than the “third”. The simple fact was that they had not reported clear of the runway so there was no reason for anyone to think that they were anywhere other than where they were i.e. still on the runway.
And the turn at the end of exit 3 would have been practically impossible for a 747 to make. Since exit 1 was closed, Captain Bragg may have thought "the third open taxiway."
@N Fels A 737 isn't a 747. The 747 has a much bigger turning circle. So thanks for calling me a liar.
Indeed. Depending on hierarchy (remember, this before the time of CRM), when asking "isn't he clear than, that Panam?" the answer "Jawel" is actually to be understood as "Yes he is".
@N Fels How about you prove that it can?
@N Fels saying that a 737 and a 747 are basically the same just makes you look like an idiot lmao
Another ironic twist of luck: Added weight lengthens take off distance. If the KLM had not refueled then there's a better chance that he would have cleared the Pan Am.
And they might not have burned to ashes.
If he hadn’t refueled then the other plane would’ve taken off an hour before. KLM was blocking the pan am plane from leaving.
Also the planes would have taken off before the fog rolled in.
It would have probably just skimmed the top..
@@jwalster9412 which would probably still have been fatal for the aircraft. Difference is less would have died on the Panam, and the KLM may have had a chance to have a more controlled crash and less of a fireball.
Th doesn't take much of an impact at that level to be fatal to an airliner, they simply aren't designed to survive impacts with large objects.
The cheese explanation definitely resonates with a lot of the disasters that you have covered. It’s usually the ‘perfect storm’ event that causes these issues.
Nothing is foolproof. But you can increase the number of fools required to cause a problem.
So what you're saying is that a cheese storm would be the deadliest of all.
It's almost every accident ever. If you had waited five seconds or gone five seconds early, that fender bender would never have happened. If you had not ordered another glass of wine, talked to the waitress, or moved your hand at the wrong time, that wine would not have spilled on your shirt. Every accident is the result of a chain of events, any one of which could've stopped the result. I used to read flying safety magazines and they all stressed this concept. It's the same for most accidents.
This crash is one of the best examples of a "perfect storm" disaster I can think of, right up there with Chernobyl and the Titanic. That perfect combination of bad circumstances combined with human arrogance and human error.
there's also a competing Hot Cheese Model, where each layer can interact with other layers with unintended consequence
think of wearing gloves while running a rotary power tool, if the gloves got entangled into the saw blades, it would increase the chances of getting hurt, even though the gloves were meant for safety
So many analogies for 'meet conditions': Perfect storm, stars line up, domino effect... The swiss cheese analogy is new to me, so thank you for the history and analogy!!
So what you're saying is that a perfect domino cheese line would be the most deadly of all? :)
@@IstasPumaNevada Dangerous and delicious... "code red: we got a perfect domino cheese line situation"
Swiss cheese is something aviation investigators use as a template :D if you want more of this, check out Mentour Aviation. He’s a pilot, dissecting various aviation incidents. It’s pretty amazing how events can line up perfectly to create the perfect disaster
it is fairly new but its easy to understand , as some people might thing some security thing is obsolete , i often seen it during covid as each layer of protection , desynfecting hands , minimalising contact , masks , washing hands is each new layer , it does not guarantee safety , nothing ever does.
The domino effect is related but somewhat different - with the domino effect each compounding error or failure is in some way related to the previous one, with the implication that each error makes the situation progressively worse. The Swiss cheese model doesn't require the failure modes to be related to each other (eg. Poor radio comms vs fog) and there is no direct implication of progressive failure as the removal of one of the failure modes can completely avoid the failure.
There is of course significant overlap between the failure modes in both models, and a Swiss cheese model often includes one or more smaller 'domino effect' failures which compound the larger problem.
Fun fact: In german the Swiss Cheese Model is called "Verkettung unglücklicher Umstände" which roughly translates to "chain of unfortunate circumstances" and I think this is another great description, because a chain can be broken by removing one segment, which would have prevented the disaster.
I have usually seen this called an "event chain". The part was manufactured with a defect, none of the mechanics doing maintenance noticed the defect, the defect caused the part to fail, etc.
My favorite odd entry in the event chain was from an plane crash, where the event chain included "it rained on Thursday". This was relevant because when the engine destroyed itself in midair, falling parts killed a farmer who was plowing his field. Which he would have plowed on Thursday, if it hadn't rained on Thursday.
So a "series of unfortunate events?"
I never knew they call it swiss cheese model in English, seems overly complicated.
I am partial to “cascade of errors”
Domino effect is the common one
While all on board the KLM flight perished, there was one KLM ticket holder who survived, because she lived on Tenerife and decided to simply take the roads home instead of going all the way to Gran Canaria. It's one of the stranger silver linings of this tragedy.
Poor lady probably suffers from survivor's guilt, so I'd bet it's a tarnished silver at best.
Her and her friends were tour guides I believe.
That's not what a silver lining means my friend.
@@petertimowreef9085 The KLM flight did have ONE survivor... who wasn't on the plane... better than 0.
@@marhawkman303 Yea but a silver lining means something positive or hopeful came out of a tragedy. And yes, her survival was positive, but that didn't happen *because* of the tragedy, she was alive before, and still is now. The tragedy didn't change anything about that.
What this tragedy did change, and what rightfully could be called a silver lining, are the changes made in aviation safety to make sure something like this never happens again.
All regulations are written in blood. Should not be forgotten.
Oh, that's why it's red tape.
Better rush to take off, we're running out of regulation work hours!
A lot of regulations are also written in bribes
just the good ones. Everything else is written in politcs
or Tombstone policy
This is the most tragic and impactful case of "get there-itis" ever and my heart goes out to the famlies of loved ones lost that day. I can't imagine coming upon this scene either; just unimaginable to see two jumbos collide, especially at an airport that normally . Hopefully we never have another accident this serious. Also the swiss cheese example is the best visualization i've ever seen of how this sort of accident happens!
I think it was Kelsey, the 74Gear pilot who said that this catastrophy changed how pilots and ATCs communicated, hence the ROGER instead of the OK, always using the airplane ID, always repeating the answers to the ATC, etc just to avoid misunderstanding and confusion.
It's interesting to learn that investigations are as much to give recommendations to step up the security work as much as finding the cause of an accident.
It may not have made a huge difference but a lot of miscommunication with air traffic control and the armed forced happened on 9/11. So most of the time because they used difference terminology they had no idea what each other were doing or what info they had. They often had no idea if a plane had crashed or was highjacked it's nuts.
It certainly changed the way that flight crews would interact with each other. One of the main reasons for this disaster was the way in which the other 2 blokes in the KLM cockpit were below Van Zanten and Van Zanten not only knew this but he made sure that they did. In his eyes, his word was law and you challenged him at your peril. CRM or CVM isn’t it?? Van Zanten thought he was a god in the aviation world and 583 people ultimately paid the price for that.
@@mrkipling2201 I am rather fascinated by the accidents, not to gloat but to see what came out of it it and I am surprised that many incidents have a happy or an almost happy ending because the pilots are communicating with each other, whereas tragic cases become tragic because pilots do not communicate and even worse, the captain don't take any advices from second officer or flight engineer, because he is the captain or has made his senior rank very clear.
Also ATC never uses the phrase take off unless it’s to give permission to takeoff.
They’ve also tried to minimize the use of non-standard terminologies.
Yes, that's right, communication has been changed.
I'm an auditor and quality professional. Whenever I give training on root cause analysis, I always include this as an example. I gave a training course last month, and people were both amazed and horrified - but I bet they never forget it.
It does seem to be more interesting than the more common chain of events analogy.
@@neilkurzman4907 And memorable. I don’t even need to look at the presentation for the details, names, timeline etc.
It’s has the same cause as the vast majority of incidents. Some saying’well i thought....and I broke protocol....’.
@@rydplrs71
Which points to an insufficient number of slices of cheese.
@@neilkurzman4907 it depends on the circumstances. You must do cost benifit analysis. You can’t automate everything, because at some point the unending task of adding cheese eliminates freedom.
Remember, this accident happened before the days of CRM, where hierarchy and seniority were more important than team dynamics.
And it was this disaster that was instrumental in implementing CRM for future flights
Hierarchies are useful when the ones to receive and complete orders are expendable or are otherwise assumed losses/costs.
When all in the hierarchy are integral for orders to be completed, and can not be so easily replaced, you have a team whether the individuals acknowledge it or not.
Teams usually exist within hierarchies. Think a of a military company (a team) within a battalion (a hierarchy).
...unlike Air France 447, where the policy was simply ignored and circumvented.
The most interesting part about this for me has always been how this shaped the airline industry after, with confirming what ATC said back to them, to confirm both sides heard correct and to make sure other aircraft hear it as well. It’s a terrible tragedy, but it definitely helped make the airline industry much safer.
It seems almost impossible to me to imagine how this wasn't protocol in the first place, but I'm naturally an extremely risk averse person and I do probably annoy my work colleagues when I call them to confirm things that they already told me, just in case I misinterpreted the situation. But a few moments "wasted" can prevent huge accidents.
Not only that, this accident was the one mainly responsible for the introduction of CRM - Cockpit Resource Managament. Basically clearly defined duties for both pilot flying and pilot non-flying, but neither is "Captain" giving orders. Each monitors the other and speaks up if in doubt - no one is to pull rank.
OK I understand your POV, however for me the most interesting part is how KLM, tried to deflect! Deny and shift thenblame? I seem to remember that it took over 15 years that the Dutch accepted the official repirt?
The most interesting thing to me about this accident is that the worst aviation accident of all time actually happened on the ground, not from an airplane crashing from the sky
I was expecting the normal kind of intro you do but cheese is so much better
Look Gromit, cheese!!
@@Benson_aka_devils_advocate_88 I’m glad someone has class, I had the same thing in my head!
@@Georgie94 Fond childhood memories, no? When innocence meant no bills, no job, no cares. Well, there is that whole tooth fairy racket...
Take care brother. Remember, it's not easy being cheesy.
It was kinda cheesy.
So... He proved yet again that everything is better with cheese.
A saying one of our pilots here has is, "All takeoffs are optional, all landings are mandatory."
There is also the old Navy aviation saying that, "the superior pilot uses his superior judgment to save him from having to resort to his superior skills."
That last is a surprisingly important point. A good airline pilot is NOT one with good stick-and-rudder skills, but one who makes damned sure those skills are never tested. Top Gun's Maverick would make a terrible airline pilot (and for the same reason a pretty bad fighter pilot too, BTW).
As always very informative and very easy to listen to. But also as always very sad 😢
“Background noise could be heard from a football game being listened to” wait so your telling me that the people in ATC were watching FOOTBALL while giving instructions to aircraft at the most critical stage of any flight.
It was in Spain I'm not surprised
As someone who almost became a controller once the controllers become familiar it is not uncommon to be able to have full blown conversations while controlling air traffic so watching a game doesnt seem so far fetched.
@@sin6453 still seems rather irresponsible
It is irresponsible, and exactly this- the paying attention to a ball game instead of diligently doing the work- has played a major role in several disasters. You can't pay full attention to one thing while paying any attention to another, and that's why there is now a "sterile cockpit" rule during critical phases of a flight where only necessary functions of the airplane and the flight may be spoken of to eliminate those dangerous distractions that people like @Michael Perry seem to think aren't an issue at all.
Damn that’s unfortunate
Seriously man, you have a dangerous talent. You can make almost any disaster easy listening. Keep doing what you do! Your content is awesome and informative.
Thank you I really appreciate that!
15:00 It is interesting that the airline wanted him to help investigate the accident, considering he already knew exactly what had happened, but he was no longer in a position to explain it to anyone.
He was 100% at fault for the accident, having taken off without clearance.
I'm not sure 100%; the ATC also has to accept some blame for failing to follow protocol, which lead to unclear, conflicting information.
van Zanten is definitely to blame in large part, perhaps even majority part, but not 100%.
@@DaWrecka ATC miscommunication was a contributing factor, but van Zanten should've known better
@@Transilvanian90 I do believe I already said that.
I've heard this one before, but even so, it's still a haunting disaster, a foggy runway, passengers on the PanAm not knowing what was going on, and the poor sods on the side the KLM was heading from, seeing a plane appear out of the fog, that being the last thing they see before they're dead, a horrific level of terror to experience, and I hope that they didn't suffer... :(
I heard the Pan Am co-pilot describing the events of the crash. He said when the KLM went over there was just a tremendous "thump", and his thought was "They missed us. How could they have missed us?"
He then saw the warning lights telling him one of the engines was on fire, so he reached for the fire extinguisher controls which are mounted on the ceiling of the cockpit, and they weren't there. Because the ceiling was gone. He said he turned and looked back over his shoulder and could see all the way back to the tail. "The entire first class cabin was gone. There were seventeen people in there."
I have also seen two of the stewardesses and one of them ... you could tell that she knew that if she hadn't left the plane when she did, she would be dead. But that also she would NEVER be okay with the fact that there were people who were alive on that plane when she left it.
@@spyone4828 His last recorded words before impact were "That son of a bitch is going to hit us!"
I still think the KLM pilot was mostly at fault. Impatient to say the least.
I’m surprised the first officer was allowed to say no to the captain and pull the throttles back to idle. Back then after watching a lot of air crash investigations there was a seniority as anything the captain did was final and a first officer or flight engineer couldn’t question or say your doing it wrong. A very very sad crash which could have easily been stopped. I think there were in fact a person or 2 people that survived the crash on the KLM flight as they disembarked the plane while it was stuck on the ground as they had a friend on the island
@@Mrwells4Q I have also watched many "points of view" around this crash. First I watched was in the 80's. I was a toxic culture back then. A lot of good came from this day. At the cost of many lives. Lockerbie is the other that I'm reminded of regularly.
@@Mrwells4Q that’s right a woman got off the KLM in Tenerife because her boyfriend lived there. She asked her 2 friends to stay with her but unfortunately they got back on the plane.
It was clearly his fault. I have lived in Holland, the Dutch have arrogance as a national characteristic.
I mean, if the excessively harsh "Safety Regulations" hadn't been in place then the pilot might not have been impatient.
Hotshot pilot: "Can we take off?"
Tower: "...%^$#%$%!$% ...#@$@#"
Hotshot pilot: "I'll take that as a Yes"
@N Fels But like PD said that wasn't the only issue at play. If the failure to follow protocol by the ATC hadn't been accompanied by van Zanten's arrogance and impatience, then the unclear instructions would've provoked a request for clarification, instead of assuming clearance and starting takeoff.
@N Fels Please clarify for me what "franco-worshipper" means. Because it sounds like "one who worships France"; being English, my culturally-mandated antipathy for the French could not be greater, so clearly that's not what you mean.
Or do you mean "Franco worshipper", meaning someone named Franco, in which case might I recommend these things called "capital letters" that help convey understanding in written form.
Accurate.
@N Fels Franco was dead for 2 years when this accident happeend, and previous to that he was in pretty much permanent state of coma for a goodwhile. Unless you know something the rest of the world doesn't i cant imagine a way in which this accident was covered.
And before you say something about the remanence of the dictatorship or whatever, spain was well on the democratic path at the time. Just shut up
Pls could you do the Leichhardt plane crash in Australia. The crash is the reason we have black boxes. Your audience could find it very interesting. Brilliant video
You mean the Mackay crash? I've never heard of a crash in Leichhardt
Having seen this incident on multiple shows, I like your way of handling it best. All the info is presented clearly and well constructed. All your documentaries are very good. Thank you for your hard work.
Certainly the best 20 minute version I have seen. Those videos (and TV shows) that I have seen explain it better took MUCH longer to do so.
I remember watching the 'mayday' take on it, it was a good well written episode and a great quality crash recreation.
(I believe 'mayday' is only a Canadian show?)
@@jwalster9412 I think I've seen it on Air Crash Investigation, which might also be Mayday. I know I've seen at least two different shows on it cause one talks to Joan Jackson and she talks about helping her fellow stewardess Suzanne climb out of the burning PanAm while the other episode does not have that piece of interview. One also has a lot of interview with the PanAm F/O Robert Bragg on it. I don't think Seconds from Disaster ever covered this. I'm limited to TH-cam episodes. I think MentourPilot covered it on one his videos but he's like PD here on TH-cam. Disasters of the Century didn't cover it either. So likely Mayday was one I've seen.
@@kriscook2423 I saw two other TH-camrs do this same topic like a week before.
@@jwalster9412 I'll have to look for them. I fall down some weird rabbit holes on YT and don't see some channels or recommendations. Somehow I always get recommended dog videos. 🤔🐕
Wow- when you posted the teaser, based on the photo I thought it was going to be the broken arrow incident near Palomares, Spain when a B-52 crashed and dropped 3-4 nuclear weapons in the ocean and over a field. So tragic and such a lesson in safety and one of its meanest adversaries: hubris.
Going on a flight from NY to Cali this month so watching all the terrible, tragic things that can happen during transportation seems fit.
Rest assured, accidents in the past have made modern air travel safer than it has ever been, and you are in fact safer flying than you are taking surface transport.
And speaking as a Californian? I hope your visit goes smoothly, and I hope your plans aren't impacted by any of our natural disasters. (Though I do hope you get to feel a _small_ earthquake, just to say you have. anything under a 4.0 is fun, IMO.)
Make sue to watch the Twilight Zone where William Shatner sees the gremlin on the wing
You’re more likely to be stabbed by a shark with a screwdriver while wearing a sombrero then be in an airplane crash, no frets friend you shall be fine
I once got a tap on my shoulder from an attendant during the flight, asking if I wouldn't mind watching a *different* programme with my lunch. I was watching Air Crash Investigation on my laptop. Hadn't occurred to me in the slightest. Whoops!
@@silvershocknicktail6638 🤣I had times like that too... First plane ride out was really persistent about your mask being up. So I would fall asleep and wake up hot, suffocating, slightly freaking out when I realized I'm in the air lol.. On the ride back we got a storm and I just kept thinking to myself *you're just on a bumpy bus ride!* 😂.
But yeah, it wasn't as bad as I thought, landing was pretty crazy. It feels like a car with really bad brakes 🤣.
Thanks everyone for the kind words, I forgot about this post.
One women from KLM survived, she didn’t reboard the plane because she lived on that island and wanted to hang out with her boyfriend
You're right, I remember this detail from the other Short Documentary I watched about this disaster.
We need a word for that. Technically, she didn't survive anything b/c nothing happened to her.
As Tenerifian myself i remember as a little kid that something terrible had happened and a picture of two burned bodies on the front page of the local newspaper.
Title: "A brief history of..."
Vid: 20+min
I love this channel.
I mean in depth documentary could be 1 or 2 hours
I used to study human factors type psychology, and find myself watching this channel a lot. It's kind of nice to finally see someone else talk about the Swiss cheese model, because I was starting to feel silly explaining it to people. As one of my professors used to say, a lot of people will look at the "human error" explanation and then move on, when that's really when the investigation starts. I get that impression with the response a lot of people still have towards Veldhuyzen van Zanten, who's behavior represents one of the things that went wrong. It's easier to believe that an accident rests on the shoulders of one arrogant pilot, rather than a series of poorly controlled circumstances (such as listening to a football match during a busy, foggy afternoon). This reminds me of another accident where an aircraft crashed after take-off due to ice built up on the wings and lack of proper de-icing: From the cockpit recording it's clear that the co-pilot is trying to call this out to the captain, but he's not using clear language, trying to draw the captain's attention indirectly. So they take off without de-icing, and they crash. Apparently this was also a problem with Korean Airlines, as they defaulted to their own hierarchical culture, and the controlling aspect of the co-pilot was lost, leading to them then being one of the most unsafe airlines in the world. Thankfully, they corrected this a long time ago.
Also, I developed a massive fear of flying from looking at all these accidents at an academic level. Frankly, I prefer nuclear disasters. But there's plenty of human factors going on in those, as well. Oh boy.
I will just kindly say, aside from the Dutch investigation; there appears to be no other report supporting that the controllers were watching a football game or that it was a contributing factor. the Spanish and American reports lean more on how the typically regional airport had controllers not trained to deal with the mass inflow of traffic; hence on the non-standard communications. It was basically two dudes, a pencil and a pair of binoculars. That was it.
I understand that one of the side effects of this accident was that some of the surviving passengers were wearing polyester clothing which melted in the heat and stuck to their bodies making the burns worse. This is why you shouldn’t wear synthetics on airplanes. I’m sure this happened in other instances, but because of the widespread interest in this crash it was brought to the foreground.
Yes you should always wear natural fibers when flying, just in case.
When I was in elementary school around the 2000's, a girl in a different school building (but from the same school) had her clothes catch on fire after hanging above a small candle light and burn about 40% of her torso.
She had been wearing nylon clothes and they were banned during the Christmas dinner (which is when that accident happened) ever since, along with candles not being on tables where students would sit anymore.
She got out reasonably well, but she says she will not ever forget the bandages having to be replaced...
I'm 52 yo and never heard this before. Will be sure to check tags on clothes I wear onto a plane. Thanks!
Polyester suits are also just way less common today than they were in the days of disco. One more thing even the most stuck-up Gen-X Karens and Kens have to admit they don't miss.
I admit, I've begun to look for cotton for my everyday clothes. Because I once set my hair on fire by being daft and I really don't want to do that again but way worse because I chose fashion over safety. I mean I don't want to set any part of me on fire ever again. But since I can't guarantee that, I can at least try to make sure it won't be a worst-case scenario.
Also I remember watching a documentary about this in Dutch. And most of the blame back then was shifted on to ATC. They refused to blame the Dutch pilot.
The unfortunate thing for KLM would always be that at the very end only one person could stop this tragedy and he didn't and it was the KLM pilot. Nevertheless the Dutch stance has always been that it was a clusterfuck and basically that for legal reasons the blame had to be put somewhere. KLM accepted after their demands were met, namely that protocols were updated to ensure that something of this magnitude would not happen again. The unfortunate thing about this is that this idea of singular blame gets retold by foreign sources, when the lesson to be learned is the exact opposite.
It is largely glossed over in this video, but yeah the staff at the airport were absolute amateurs. In the country of Spain in those days people working in government jobs were usually complete halfwits who got their job through nepotism and corruption. This country had suffered decades of Franco, it was essentially a third world country. Spain today still falls short of expectations when viewed from a Dutch perspective, but when it is compared to the 70s the effort made is nothing short of magnificent.
@@utoesc6241 Both ATC and the pilot could have stopped it, they are both to blame. Saying "OK ... " with a long pause, to a question whose answer is NO, is completely unacceptable as well as the pilot's decisions.
I'm an American but because of this channel I've caught myself using "balls!" as an expletive lately.
Remember the news reports as a 15 year old. 😬 Still get chills every time I see or hear something about the disaster. The next summer it was the Los Alfaques tanker explosion...
A terrible tragedy, and as another comment says, the next year there was yet another horrible accident in Spain at Los Alfaques, Tarragona, when a propylene tanker exploded next to a camping site that was full of people on their summer holidays engulfing the whole place in a literal cloud of fire. As another interesting event, the Palomares incident from 1966 is remarkable in including all at once: nuclear material, a broken arrow event, and aircraft collission in mid-air. The incident is briefly shown near the ending of the 'Men of Honor' film, with Cuba Gooding Jr. in the role of who would become the second African American master diver in the US Navy.
The fascinating horror TH-cam channel did a video on that incident. Pretty horrifying
I immediately thought of that video!
So it's cursed then?
A lot of unfortunate things happened:
If no attack it would not happen.
If KLM didn’t refuel, it could in theory climbed away. And they won’t take off in fog.
If PanAm didn’t miss the exit, the crash won’t happen.
If no ATC communication confusion, it will not happen.
Arguably, if KLM didn’t drag their tail on the runway they could have less damage and may survived.
Regulators can’t do anything about anything other than the ATC communications, so that was exactly what they done. ATC communication had been revised to such extant it is now very professional, and a regular person won’t able to blend in “Catch me if you can” style.
I see the recently-introduced Dutch law on overtime as another factor. If they just added in an exception in the event of extenuating circumstances, this crash may have been averted.
@@youngwii You are exhibiting one of the problems that gave teeth to the Dutch law. Everybody thinks that they are good enough to grant themselves an exemption to regulation, forgetting that the disasters that led to that regulation had a root cause in people thinking that they were fine doing it that way "just the once", or that "they had always done it like that before."
Tbh the KLM actually had an option to avoid the crash, as an experienced pilot should have known takeoff was impossible in the distance left to them.
They could have chosen to park it in the grass, a dangerous manuver but with a much higher chance of survival than risking the takeoff.
Basically slam on the breaks, and turn off the runway to the left. I'm not sure but I think this is actually a standard procedure now, always to the left (so that both aircraft turn opposite directions). I could be wrong though.
@N Fels the Panam litterally reported they had not yet cleared the runway, that is them reporting it. The basic rule of airport traffic is "unless someone has reported they have finished doing something, they haven't finished doing it, never assume otherwise", and the KLM broke that rule repeatedly. First they knew that the Panam was on the runway, and never got clarification that it was clear (radio issue there admittedly), and secondly their pilot cut off the readback, you never cut off the readback, thats radio protocol 101, an order isn't an order until its both given, confirmed, and the confirmation is confirmed.
@N Fels If i was to be fair, the ATC controller was a contributing factor, no arguement there. But I would still put the majority of the blame on the KLM pilot as he failed to follow already accepted protocol.
The messy communications and rude ATC controller just mean you need to be forceful. If communications are unclear, you ensure that they are forced to be clear with you, especially when you have responsibility for undreds of lives.
The weather was poor, thats accepted.
The runway wasn't clear and you haven't heard otherwise, so its still not clear until you hear otherwise.
The ATC instructions were a mess, but you double check, and get confirmation.
Everything else could have failed, but provided the person at the controls doesn't mess up, its all still salvagable. That they messed up means they failed in their duty, and at the end of the day, their core duty is the passangers safety first. The pilot been distracted and rushing because of the laws regarding working times is no excuse, it just partially explains why it happened.
So yes the ATC controller is partilly to blame, they were unprofessional, the Panam crew were partially to blame, they never got confirmation that everyone understood they were still on the runway, but the KLM pilot is the one who killed all those people, as had they litterally taken 30 seconds to confirm things, hell even 10, it never would have happened.
I thought I'd seen everything about this incident but you've actually told me a couple of things I didn't know, good work as always. Thank you
There was also one passenger who got off the plane (Pan Am 1736) at Tenerife that lived there. I think she was the only survivor of her plane (because she was at home instead)
Do you mean the woman who got off the KLM because her boyfriend lived in Tenerife??
She was the one beneficiary from the bombing attack because her flight rerouted to her destination. She was going to be taking a ferry over from Gran Canaria the next day to get home and asked herself, "Why bother?"
@@Markle2k wonder if she had survivor's guilt
@@moelll Was kind of wondering the same. Having never experienced survivor's guilt it always seems to be an odd struggle of emotion vs logic. Looks like a terrible experience to endure.
There have been several recent videos on this disaster, but yours included a number of details I hadn't heard before. Well done.
This disaster is such a perfect example of a perfect storm, so much went wrong that it only could end in disaster
I was wondering when you were going to get to this one. This still stands as the single largest loss of life on an airfield. This also changed the way ATC facilitates communications with aircraft. It was a lack of ground radar; the inability to see the field due to fog; miscommunication due to the tower controllers not fully understanding what they were being told; and a major rush by a airline captain who insisted on holding things up unnecessarily to refuel, which all came together with devastating effect. His arrogance that day was quite deadly. Excellent video!
I think it is still the second most lives lost from an aircraft incident.
"Here's a few seconds of PD pulled a children's dog toy along the carpet."
Me, for some damn reason: :D
Interesting you mention Human Factors, as that's one of the core safety courses now taught within the aviation community, with the dirty dozen being one of the core things taught within it.
The nuclear navy uses the concept of 'defense in depth'. You never, ever depend on one person or one system to get something right. There must always be backups, whether it's keeping cooling water on a reactor or writing a good proposal for an ERP system update.
If your designong a car you don't want it to pull a pinto on a crash, so yeah, that makes sense.
I like your swizz cheese analysis. Another slice of cheese to add is that the KLM crew under the captain were quite new and the captain wasn't only their captain, but the captain of captains of their company. They daren't speak out against him and when they did over something so important as questioning if the other plane was clear of the runway, the captain fobbed them off without checking. Since then captains of all airlines are told to listen to their crew and the crew are told not to be worried about challenging their captain's desicions.
This disaster was mainly the fault of the arrogance of the KLM Dutch pilot.
Nah, it was mainly the fault of decadent European labor law.
@@mushyroom9569
It’s the fault of every event that led up to it. Trying to pick the one event it’s not a good use of one’s time. Every cars needs to be addressed. Not just the one that strikes the investigators fancy.
This was 1977. I don’t think European labour law was even a thing at that point.
@@GorgeDawes
There were regulations on how long a pilot can fly. Apparently the captain of the KLM aircraft was concerned about going over time. Which may have caused him to act impatiently.
That was also compounded by the airline rolls. If he went overtime then the plane would be stuck there and would cost the company money. If he flew too long he could get his license suspended. Both options unpleasant. His best course of action was to finish the flight.
@@mushyroom9569 That "decadent European labor law" came about because of disastrous incidents like this one caused by overwork without a rest period. And due to people thinking that they were "just fine" and could thus ignore the law, there were teeth put into the law.
People tend to think that they are the exceptional ones, especially if they have "gotten away with it before" or they excuse themselves with "this is how I've always done it and it's never been a problem". One of the perverse things that happens in this world of Crew Resource Management is that having several very senior pilots on board decreases safety due to overconfidence in their proficiency. Part of the reasoning behind the Swiss Cheese Model is that often several unfortunate coincidences have to line up to create a preventable disaster.
My wife: what are you watching?
Me: a video about a plane crash
My wife: why is he talking about cheese?
Me: its plainly difficult to explain
Your coverage of this is worthy of an episode of Mayday: Air Crash Investigation!!
(or however it's called where you live, everyone knows that show ^^)
There is already an episode of that show covering this exact accident 🙂
@@bjarkeistruppedersen8213 two in fact haha
The tragic part of the rule that was ostensibly put in place to protect pilots, the cap on hours at the controls, was weaponized against them, which was a major factor in this crash. When a rule like that can end up with the pilot in handcuffs, _wow_ is it missing the point.
Leave it to government and bureaucrats to decrease safety with safety rules.
“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies. The robber barons cruelty may sometimes sleep, his cupidity may at some points be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.”
@@Crosshair84
Leave it to people like you to think no rules at all would’ve made things safer.
The rule still exist today. They’ve just been modified to avoid this issue.
He wasn’t concerned about going to prison. He was concerned about being fined or having his license suspended.
Next time you complain that it will regulation is a small book you can look at this event to see why.
You can also remember that pilots flying tired has caused several major crashes.
The point of these investigations is to find all of the causes of a crash. And to fix all of them. Reducing the number of holes in the cheese.
@@neilkurzman4907 Hope you had fun ranting against an argument that nobody made. I'm sure nobody is impressed.
I wish you success in your travels at getting upset at things people didn't say.
Experience is no guarantee that you will not make mistakes. If anything, I think the more experience someone has the greater the danger due to complacency or hubris. I have noticed that many people who have lengthy experience in a field tend to believe they are, for the lack of a better word, invulnerable. I see it in pilots, outdoors enthusiasts, drivers, engineers, medical professionals, etc. While a novice makes mistake due to not knowing, the experienced person makes mistakes by doing things fully aware of the dangers, but still ignoring the same dangers. It's as if the more experience they gain, the more they are willing to break the rules because they feel they are above the rules; that their experience makes them an exception.
Sadly all that could fail, failed, and a curious detail, 2 years ago a part from the Pan Am plane was found 3km away from the original crash site, it was a horrible crash that even today it haunts the TNF Norte airport
As horrible and apathetic as I probably sound... I can't be the only one who thinks the picture of the locomotive bursting out the station looks really bloody cool.
And it only killed one person, an unfortunate newsvendor that was hit by falling debris. Gare de Montparnasse, 1895.
The engine wasn't much damaged - steam locos were bloody tough.
Well, you take the human lives lost and misery caused, pretty much all accidents are cool.
@@cr10001 I recall it being an album cover but I can't recall which.
I mean, I've got a strange fascination with shipwrecks, and have even gone wreck diving in the Great Lakes a few times. With the old ones, it's like going back in time, underwater, and seeing history. A lot of the most interesting bits of history also happen to be the parts where bad things happen to people.
Either that or we're all just morbid bastards.
@@youkofoxy Accidents can be quite funny, especially if no-one gets seriously hurt. Watch car rally videos for some entertaining ones (usually the crew are well strapped in so they qualify as nobody hurt except the car)
A surprising number of channels have covered the Tenerife disaster over the past few months. I've been looking forward to PD's presentation since the teaser pic. As usual, I found PD's coverage informative, entertaining, and riveting. Bravo!
This was one of the best videos I’ve seen on TH-cam about Tenerife. Very well done. Hearing the impatience that led to this makes me angry, but I see how many factors also coincided to cause this disaster. I’m relieved it resulted in better procedures and safety standards. To those who passed, I hope you are resting in peace.
“Anything that can go wrong, will go wrong”
That is the littoral definition of what happened at Tenerife
I was tricked into joining the navy. I thought the recruiting officer had a speech impediment when he kept saying "Littoral combat ship"
That’s not the lesson to be taken from there. The lesson wise to find everything that went wrong and fix every problem. Not just to throw up your hands and say oh well could be avoided.
What was learned on that day has probably saved many airplanes from crashing.
@@marionette5968 Well it's *meant* for combat, literally along the coasts.
@@marionette5968 Well, you were half right, haha. I've never seen someone mistake "littoral" for "literal". This is an interesting one.
@@aerodynamicist4 It's a fine demonstration of the Swiss Cheese Model not stopping all mistakes. The final slice being the holes in the autocorrect's slice where "literal" and "littoral" are both in the dictionary. Google Chrome's autocorrect seems to have an additional -slice- layer of context or grammar filtering as it is gray-squiggly-underlining "littoral" and suggesting that I may have meant to type "literally" in my second sentence.
It's always interesting to see different interpretations of this catastrophic disaster. Very nicely done!
I've always thought that in a circumstance where the controller cannot see the planes and the planes cannot see one another then the controller has to deal with the situation in a completely different way. This is something that doesn't apply during the day or during the night. Practically zero visibility is a unique situation. You cannot therefore treat it as the same as other situations. There are assumptions made during daylight and at night that planes can see one another and therefore will be able to avoid a catastrophic error like this. The controllers therefore have to modify the way they control the planes. They have to ensure that two planes are never on the runway at the same time and that they are clear at all times where each plane is and that each plane knows where the other planes are. They should order all planes to stop until they establish this and make sure everyone is clear about their locations. There should also be informational messages to all aircraft on the frequency instead of just giving a call sign for a particular plane , which tends to cause pilots to ignore messages not directed at them. If the controller had contacted the KLM pilot and said 'The Pan Am plane is still on the runway. When he is clear of the runway I will contact you. Please acknowledge' this would never have happened. It would be a non-standard message but it is a non-standard situation.
This is why formal procedures were developed subsequently for operations in low visibility conditions. One of the guiding principles is that a runway should only ever be occupied by a single aircraft at a time, whether that aircraft is taking off, landing or simply taxiing into position.
@@GorgeDawes I believe it was after this that they also had lit signs on taxiways and other improvements. What is frustrating about this is that it took this major accident to make clear dangers that were already there and had been there for years.
I think they also have ground radar too
Well done video…in the report is the fact that the KLM actually refuelled mentioned as a contributing factor to the after crash fire and if the added weight of the fuel prevented the KLM flight from cycling quicker and possibly missing the PanAm flight?
It’s a horrific example of compound errors.
Anything you cover is always extremely well done. That's why I love this channel. Very good
Another great video! Honestly, I don't think I've ever been disatisfied with any of your videos. Of course my heart goes out to friends and family members, even after all these years I'm sure the pain lingers.
I have known about and watched numerous accounts of this incident across the years.
Yours is very well done and adds an extra detail (ref the apparent watching of a football match by somebody within earshot of comms) I had not previously known about.
Thanks for covering this.
Loving the cheese intro! You make historical events much more interesting you need your own netflix series!!! I have started binge watching your channel while I'm sick!
As others here has commented this absolutely tragic but avoidable incident caused huge changes to happen in aviation. I have sat in so many CASA aviation safety briefings (my dad is a pilot I am his radio operator) that have either explicitly told this story or referred to it as an example of just how terrible things can get when pilots get tunnel vision or became complacent.
While I still encounter pilot ego and hubris (I think they have to have at least some higher level to take huge engines with wings into the air) the impact of the ego and hubris can and is held in check by policies, procedures and standardisation. Most importantly the CRM or Crew Resource Management trying to remove hierarchy and seniority from the cockpit and instead everyone agrees on the next action and is encouraged to speak up in situations that they don't.
While I hate the reality of safety being written in blood I am grateful that aviation is safer because of it. I just wish other areas of society took a page out of the aviation safety book. If they did we might not have tragedies like crowd crushes, bridge collapses or radiation accidents.
Long-term fan, Dutch, I'll admit that bias, but as aviation nut, fairly disappointed you didn't go into Crew Resource Management, which (lack of) was also a major contributor to the incident. It was the incident to completely change commercial aviation, because this incident lead to implementing CRM...
I remember when this happened. So sad for all involved. The swiss cheese model is an excellent way of explaining how a cascade event occurs. Great video
Since learning about this I never fly with KLM. Their whole attitude were to deny responsibility from the beginning.
You realise this was 44 years ago, right? How many fatal accidents has KLM had since then?
@@GorgeDawes I don't want to be in the next one.
The most annoying thing is the people trying to say that the captain who tried more than once to take off without clearance who had a toxic relationship as captain and actively ignored standard safety precautions by choosing to act ignorance is excused over a crew that had active communication with ATC.
A good short information-packed account of the disaster. I’ve heard this also spurred the movement to Cockpit Resource Management (CRM).
There was one woman on the KLM flight who survived, because she lived on the island and decided to not get back on the plane just to come back home the next day. The airline told her not to do that, but she ignored the instruction.
That French train disaster you showed with the cheese looks very curious. Is that worthy of a video?
It's the Montparnasse train derailment, apparently, and very famous.
@@multiplyx100 But it wasn't really a 'swiss cheese' sort of accident, more just a misjudgement by the driver who came in too fast and braked too late. And it only killed one person, an unfortunate bystander.
There was a much more 'swiss-cheese' (and far more deadly) failure to stop at Gare de Lyon in 1988.
I'm so glad you covered this accident. I find it such an intriguing series of events and one I enjoy looking into to find out more about it since everything that could have possibly gone wrong in a plane crash went wrong and without even one such factor the incident wouldn't have occurred.
I've only recently started watching your content and it's very much enjoyable for me as it's my kind of intrigue and enjoyment.
Excellent job on this, such a terrible incident. Love the cheese analogy!
I've seen this accident broken down by so many different youtubers but I've been. Waiting to see you do it. Yours are always the best.
I had that puppy toy when i was young. To think I'd see it here of all places given I'm almost across the world in Latin America.
I had the same toy too. And I'm also from Latin America. I think I still have it somewhere.
Children are much the same everywhere, and many toys will appeal to all of them so are sold worldwide.
It's sad that most of these from the 60-80s are loaded with lead and other nasty things.
Oddly, I've always been like the old man in Moonstruck with all the dogs following him. So I never had this one. I'm guessing it was late 60s...?
Better than most TV shows I've!
Straight to the Facts , No Tail Chasing to Stretch Watch Time
They should’ve had a clause in that work time law that said “the only exception is in an emergency situation.” Like this one. There were bombs involved and diverting the planes and the fog and so many factors.
''Crash of the century'' is one of my favorite disaster docos! The reconstructions are very well acted and overall production is great!
Someone was definitely hungry while thinking of an analogy for multiple safety system failure. Mmm, yes, cheese.
I was 15 when this disaster happened. I definitely recall hearing about it on the TV news. The loss of life was shocking.
A perfect storm of events that bted an inevitable disaster. Sad that Van Zanten ignored all the warning signs that said to stay on the ground.
One passenger from the KLM flight Robina van Lanschot a tour guide didn't re-board the flight. Her boyfriend and her lived in the island and it made no sense for her to go to Gran Canaria and go back to Tenerife the next day. She left her ticket and luggage at the airport went home to her boyfriend. That saved her life.
That one pilot was absolutely moronic. Seems it mattered more to be on time rather than protect human lives.
Right. If it was a clear day I'd maybe understand his actions but in fog dude had a deathwish
Part of his concern was a moronic Dutch law on crew working hours.
He was keen on following Dutch "Safety Regulations".
@@washingtonradio Well, that's just as terrible.
@@washingtonradio That "moronic" Dutch law was implemented due to disasters caused by overwork and fatigue. It was given teeth because, without meaningful enforcement, people gave themselves permission to be Superman.
The law was not there to give people cushy working hours, it was there to prevent incidents like this one.
Fascinating Horror actually covered this some time ago themselves, also a very good video to be checked out!
I don't think the Swiss cheese analogy has anything to do with lining up the holes, but that the more slices you have the less likely it is to be able see all the way through one hole with each slice being a safety precaution
I suppose the Swiss analogy can be used in several ways. Murphys Law and safety protocols can be applicable for sure.
he messed up on the analogy as the swiss cheese model works when all the slices are aligned and you swap out each slice of cheese in perfect alignment to show or obscure various holes, not shuffle them around like floor tiles.
That's the exact same analogy but with different words lol
The point of any of these analogies is that a single failure is not the cause of many crashes. It’s multiple failures.
And the more layers of protection you have the less likely they will be for that hole to exist.
@@neilkurzman4907 It also points out that no system or procedure is perfect in assuring safety or success; everything has some flaws (holes) in it where failure becomes possible.
Oh man, little Snoopy! I had one of those as a child, I am 58 lol. Thanks for the memory.
The concorde crash "Air France Flight 4590" would be an interesting one.
Mentour Pilot did a video on that one about two weeks ago, _highly recommended._ His entire series on airplane incidents is amazing and incredibly informative.
i saw this disaster covert by an other youtuber named fascinating horror and I have to say, that its worth it to watch both. in this video the crash and everything around it is more detailed but in the other video he explains more what happend after this to prevent such tragedies to happen again.
but you made a really nice job I love this video so much. Their nice to listen to and are detailed
Did you know Flight 4805 had one survivor? (I should have posted this on the Patreon, my bad) Robina van Lanschot was a tour guide who opted to make her own way home to Tenerife rather than reboard the plane, a decision that although was apparently against the rules would ultimately save her life. Her remarkable escape is mentioned on both the Wikipedia page and the Air Crash Investigation episode Disaster at Tenerife.
As an add, that terrorist group must have been sh*tting itself when they heard the fallout from their bombs.
Another Great video, and Excellent narration/thorough explanation!!!
I REMEMBER this accident like Yesterday.....I think it could have been my earliest 'disaster' ( WaterGate [historic] and this ) in my 50+ years. And EACH TIME, literally each time, I'm on an airplane ... taxiing, I would ALWAYS look at the nearest window to check for A/C on runways...kinda scares me even today!!!
Again, 'PD' Great vid...thanks for ALL the HARD Work in RESEARCH you do!!! You are a Superior Researcher...... and your animation is good also!!
The new law contributed to the disaster. The KLM pilot took on fuel and wasted half an hour because he was worried about this bit of bureaucracy. I understand that flying tired can be a problem, but bureaucratic laws put pressures on people. This leads them to look for work-arounds so that they can comply with the rules. If not for that law, the KLM plane would have taken off before the fog descended. The plane would have been an hour or so late getting home. The pilots might have been over the arbitrary limit, but they and their passengers would be alive.
Bureaucrats need to understand that they shouldn't be making absolutes. Physics and mechanics are absolutes. Two planes trying to occupy the same space at the same time is a disaster. That's an absolute. A plane fully loaded with fuel not being able to take off as quickly and burning more completely on crashing is an absolute. The problems of seeing in a fog are absolutes. Bureaucratic rules should never be an absolute.
@N Fels No, that's just not true. Bureaucratic thinking is never an absolute. The death toll from being tired is not "staggering." Things happen, but they aren't that regular and certainly aren't "staggering." Bureaucratic rules are never important compared to physical science. Bureaucrats are too stupid to understand that, but that just means that we have too many bureaucrats in this world.
I've heard this story like 5 times now from different TH-camrs. Yours is definitely the best imo.
Today I learnt that the Canary Islands had a separatist movement
Who didn't in the 70's.
@@LMB222 In Africa I think they spun a wheel each week to see which country would have a coup or revolution.
I do remember some discussion about the fact the KLM captain was also a simulator training captain and therefore was issuing the air traffic control instructions in the simulator and this is thought to be a factor in the accident, he basically issued the clearance in his mind just like he was doing in the simulator
Usually back-tracking as opposed to back-taxiing when you have to taxi then turn before takeoff
I'm excited for a series of aviation disaster videos from you sir! You should do the Hindenberg next. I think hydrogen got a bad rap. The reflective coating was extremely flammable and terrorism wasn't ruled out either.
The paramedic "teacher" for ethics had a great example for paying attention. He would take out and egg and hand it to someone in class, then every few minutes would take the egg and hand it to someone else. At the end of class he threw the egg to the floor. "This is what happens when we screw up with head and spinal injuries, people end up as scrambled eggs" is what he said afterwards
sounds like you need a better teacher.
I dont get what the fuck is the lesson there
@@verybarebones exactly, I think his point was to assume someone would drop it, but since that didn't happen, he had to prove that he, himself would be unprofessional.
That would sure leave an impression, but it sounds like the wrong impression to me.
If he'd "accidentally" dropped it after taking it from the final student, I feel it would have given a better impression; that anyone can make a mistake, even the one everyone is supposed to be learning from.
@@IstasPumaNevada The impressive nature of an exploding egg just drives the point home. It's about the fact that everyone has to be on the same page before and during something that requires extreme care like head and spinal injuries or controlling aircraft movements
I remember seeing this on Air Crash Investigation. Horrific and avoidable disaster the whole way through.
"Now I've got you thinking about tasty cheese. You might be asking what has this got to do with anything?" Except that we've watched your videos before. Heck, this could practically be the Swiss Cheese channel. ;)
Meanwhile, on the Swiss Cheese channel:
“The holes in Swiss Cheese are a lot like aviation disasters”
@@alexroselle you got that from the Simpsons, the orange eating and marriage class episode.
This episode was well done! One thing to remember is that some of the communications were cut off (both planes and tower). The Smithsonian channel has parts of the Air Disasters episode about this on TH-cam, including an interview with one of the Pan Am co-pilots