Final Year Presentation of Air Accident, Safety and Investigation of Boeing 747 accidents

1. The Tenerife Disaster
Erica Gill
70074724
Lahore School of Aviation
Aircraft Safety Accident Investigation

2. Overview
● March 26,1977.
● Los Rodeos Airport, Tenerife
● PanAm 1736 (396 pax)
● KLM 4805 (248 pax)
● 583 out of 644 died
● 61 survivors.
● Political Friction (MPAIAC)
● Flight Conditions-Low Visibility

3. Route for PanAm 1736
Los Angeles
International
Airport
JFK
International
Airport
Las Palmas
De Gran
Canaria
Airport

4. Route for KLM 4805
Amsterdam
Airport
Schiphol
Las Palmas
De Gran
Canaria
Airport

5. Crew of PanAm1736
● Capt. Victor Grubbs (56 y/o)
● First Officer Robert Bragg (39 y/o)
● Flight Engineer George Warns ( 46 y/o)Warn

6. WEATHER

7. Takeoff Clearance

8. Miscommunication
.

9. Factors
• Weather (Rolling Clouds)
• MPAIAC
• Van Zanten had most hours on simulator for 747 fleet.
• Startup clearance was done by Capt instead of FOO.
• Los Rodeos was insufficient for this traffic.
• Los Rodeos had a poor safety record.
• Lack of Ground Radar at Los Rodeos.
• KLM flight crew was anxious for working hour limitations.
• The refueling made the jet 15 times heavier.
• PanAm had to wait for KLM to finish refueling.

10. Factors
• Miscommunication.
• Runway Center lights not functional.
• ATC: “7135 report when leaving the runway”
• There were supposed to be four ATCs but only two were present.
• Watching football was mandatory?
• KLM advanced the thrust levers without ATC clearance.
• Charlie 3 exit had two 148 degree turn.
• Pan Am asked that they should wait for KLM to takeoff but it was never received.

11. FINDINGS
• KLM Captain taking off without clearance.
• As instructed by ATC KLM failed to stop takeoff.
• Failing to abort takeoff when PanAm reported they were still on the runway.
• Ignoring when their own flight instructor identified the conflict.

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Lahore School Of Aviation
Erica Gill
70074724