Lessons Learned

Technical Lessons
Clearances to move for flight to take off or land should clear and unambiguous.

The following messages were audible in the KLM cockpit:

1705:44.6 KLM RT :Uh, the KLM 4805 is now ready for takeoff and we're waiting for our ATC clea
rance.
1706:18.19 APP :Okay.
1706:20.08 APP :Stand by for takeoff ... I will call you.

In this accident, the unusually congested of airport requiring to use all available taxiways and the r
unway. The worsen of weather reduce the visibility of the crew.

KLM flight and Pan Am flight back to the runway at the same time in order to departure from the a
irport.

The KLM flight completed a 180-degree turn at the end of the runway and waiting for takeoff clear
ance.
The control tower passed an ambiguous message to KLM flight and they begin to takeoff.
At the same time the Pan Am flight still at the runway and going to the proper taxiway.

 Flight crew communications regarding airplane safety should be open a

nd effective.
Each of the crew member should say out their opinion or their question
and their opinion should respect by others member.

The following messages were audible in the KLM cockpit, causing the KLM flight enginee
r, even as the KLM plane had begun rolling down the runway, to question the KLM pilot:
1706:25.47 APP :Ah-Papa Alpha 1736 report runway clear.
1706:25.59 PA RT: Okay, we'll report when we're clear.
1706:31.69 APP :Thank you.
1706:32.43 KLM 3 :Is he not clear, then?
1706:34.10 KLM 1 :What do you say?
1706:34.70 KLM 3 :Is he not clear, that Pan American?
1706:35.70 KLM 1 :Oh, yes. [emphatically]

In the accident, the flight engineer heard the Pan Am crew state that will report to to
wer when they were clear from the runway, means that they still on the runway.
The engineer asked the KLM captain twice about the Pan Am flight still on runway.
The KLM captain not believe to him and just answer Oh, yes. and continue to tak
eoff.
The other crew members did not further question the captains action due to his seni
or position.