UNIVERSITY OF SAAD DAHLEB BLIDA 1

INSTITUTE OF AERONAUTICS AND SPACE STUDIES

Analysis of the final report

The collision of KLM flight 4805 ,Boeing 747-206B,PH-BUF

And Pan American flight 1736 ,Boeing 747-121, N736PA
At TENERIFE airport ,Spain on 27 th ,March 1977.

Family name : CHAREF

First name : WIDED

Field : AVIONICS

Scholar year : 2019/2020

 The scenario  :

In March 27 th,1977, two B747 airplanes ,one KLM (Royal Dutch airlines ) ,and the
other one Pan AM (American airlines ). Both airplanes diverted to LOS REDEOS airport
in Tenerife next to other aircrafts since a bomb exploded in the airport previously
selected for both flights (LAS PALMAS).
The KLM flight landed at TENERIFE first at 13:38 and its passengers were transported to
the terminal for a while .The Pan Am flight landed at 14:45 but its passengers stayed on
board.
After the reopening of LAS PALMAS airport ,the Pan Am was immediately ready to
depart but it was parked behind the KLM which was refueling and preparing its
passengers for the flight (there were no space in the runway to pass next to KLM due to
its structure).
On the day , fog and clouds decreased the visibility , both ATC and planes counted on
radio communications for information on runway positions. The ATC gave instructions
to KLM to taxi down the takeoff runway till the end and then backtrack and wait for
takeoff clearance .
The Pan Am flight was asked to follow the KLM on the takeoff runway ,turn off at the 3 rd
taxiway by its left(C-3) and use a parallel runway (to the one of KLM) for the rest of its
taxiway.
While the Pan AM captain missed C-3 and continued to C-4 (he was confused about the
3rd taxiway since C-1 was close). KLM requested for takeoff clearance as records shows ,
released the brakes and began the takeoff phase ,than said :’we are ready for takeoff’ ,
ATC replayed :’OK’ followed by ‘stand by for takeoff ‘.this part of message wasn’t heard
by KLM flight.
Meanwhile Pan AM was still taxiing the runway and send a confirmation message to the
controller saying :’we are still taxiing down the runway’ , the ATC received this message
as a respond from KLM not from Pan Am (communication was interrupted ),thinking
that KLM did not start takeoff. At moment where Pan Am reported that the runway is
clear . KLM was climbing , The collision happened(17:06 pm) and the ATC did not
receive any messages again from both flight .
 Note:
Both planes were aware that the lights of the runway centre line were out of the service
since the ATC announced that in middle of the conversation.

Analysis:
Miscommunication:
Various factors resulted in imprecise of communication ,it is mentioned that :
1. The controller was difficult to understand (lack of English language),also ,inadequate language
was used when the KLMs’ co-pilot said :”we are now ready for takeoff” and the ATC replied :
“OK” at first made the pilot believe he had clearance for takeoff.
2. Technically the two overlapping radio transmissions resulted a disturbing sound and loss of
clarity (messages between two planes and ATC were mixed up ).
3. For Pan Am flight , they requested permission for taxiing the runway ,it was confirmed by the
ATC , adding that he told them to leave the runway by the 3 rd taxiway to their left .Pan Am crew
heard “the third and then the first” , making them confused between C-3 and C-4.
4. The controller did not main control of aircrafts (provided unclear instructions for both crews).

Visibility ( weather conditions):

As records shows , the airport was equipped with various meteorological equipement that
showed :
1. The weather changes from time to time , approximately each 10 min , that ended with a reduced
visibility of 300 m to 1000 m.
2. The fog was so thick , rain was light and cloud coverage was large that neither aircraft could see
the other one, and the controller in tour could not see both runway and the two 747s on it.

Environmental conditions:
1. Many aircrafts were parked at the same runway that say at the same time .
2. Runway centre line lights were broken.
3. Runway structure didn’t allow one airplane to pass next to the other one.
 Human factors:

factors aspect details

The limitation of duty time
Time pressure psychological put the crew of KLM under
time pressure , to either
takeoff soon or to interrupt
the flight (because of weather
) and that would make the
company sue them .

Since the captain of KLM flight

authority gradient: psychological was an experienced pilot , the
co-pilot couldn’t doubt the
decision of his captain or
question it ( he tried once
where there were no ATC
clearance but the captain
didn’t borrow him any
attention. Sam thing for the
question of the flight engineer
about the Pan Am flight on the
runway and totally ignore it
as it is showing in records.
The delay of the Pan Am flight
Irritation: Physiological
,the changing weather and the
time frame (that caused
missing the taxiway C-3) .
 Recommendations :
 standard procedures for communication in English (aeronautical language).

 air traffic controllers should provide other systems of position , communication , weather and

safety, for an effective control of traffic in takeoff , landing and on taxiway in case of low

visibility.

 The use of Clear terms while communicating and the avoidance of the word “takeoff” in the ATC

clearance.

 Teamwork , and no decision should be made without the agreement of the cockpit members.

 Concerning this airport , they should declare weather conditions and provide necessary

procedures to face situations like this.