Abstract
The Tenerife disaster serves as a classic example of how small seemingly benign errors can produce horrific consequences. There exists a frailty between psychological factors such as situational awareness, communication or crew resource management that if not understood or followed can begin a domino effect of epic proportions. This paper summarizes the contributing factors involved in a collision at the Los Rodeos airport between two 747 jumbo jets in March 1977 killing 583 people. Key words: Crew Resource Management, Stress, Communication
Introduction It seems implausible a pilot with extensive flying experience would take-off from a controlled airport without prior clearance. Yet this was the primary reason given for the …show more content…
Standard phraseology in aviation designed to promote understanding became ambiguous at critical times with the KLM crew using such phrases as “we are now at take off” after receiving a departure clearance that included ambiguous words like “cleared” and “takeoff” but at no time included the statement, “cleared for takeoff”. Furthermore, the KLM crew to crew communication reveals a dysfunction in group communications with the co-pilot and flight engineer expressing their concerns, but only doing so in a manner to phrase statements as questions, possibly as way to minimize conflict and further legitimize the captain’s role as primary decision maker (McCreary, Pollard, Stevenson, & Wilson, 1998). This form of communication illustrates the lack of cohesion amongst the crew members. Highly cohesive teams focus on the process, and not the individual, something that can be observed in any evolved employment involvement team or flight crew. The KLM crew, more specifically the co-pilot and flight engineer failed to sufficiently pressure the captain to step back and look at the situation (the process) but instead went along to get along. This also shows a lack of skills pertaining to crew resource management. The goal of CRM is to encourage each member of the crew to freely question authority not for the authority to remove the crew from the loop of making decisions. This crew was obviously intimidated …show more content…
The KLM crew was required by organizational policy to not violate flight and crew duty times that resulted in delays without facing severe penalty. The next hole in the defensive layer is the poor qualities of the KLM captain as a leader, who seemed to be fixated on meeting departure times at all cost regardless of the input received from other crew members. Pre-conditions include deteriorated weather, poor communications between the controller and the KLM crew and between the KLM crew members themselves and finally radio frequency
The Tenerife disaster serves as a classic example of how small seemingly benign errors can produce horrific consequences. There exists a frailty between psychological factors such as situational awareness, communication or crew resource management that if not understood or followed can begin a domino effect of epic proportions. This paper summarizes the contributing factors involved in a collision at the Los Rodeos airport between two 747 jumbo jets in March 1977 killing 583 people. Key words: Crew Resource Management, Stress, Communication
Introduction It seems implausible a pilot with extensive flying experience would take-off from a controlled airport without prior clearance. Yet this was the primary reason given for the …show more content…
Standard phraseology in aviation designed to promote understanding became ambiguous at critical times with the KLM crew using such phrases as “we are now at take off” after receiving a departure clearance that included ambiguous words like “cleared” and “takeoff” but at no time included the statement, “cleared for takeoff”. Furthermore, the KLM crew to crew communication reveals a dysfunction in group communications with the co-pilot and flight engineer expressing their concerns, but only doing so in a manner to phrase statements as questions, possibly as way to minimize conflict and further legitimize the captain’s role as primary decision maker (McCreary, Pollard, Stevenson, & Wilson, 1998). This form of communication illustrates the lack of cohesion amongst the crew members. Highly cohesive teams focus on the process, and not the individual, something that can be observed in any evolved employment involvement team or flight crew. The KLM crew, more specifically the co-pilot and flight engineer failed to sufficiently pressure the captain to step back and look at the situation (the process) but instead went along to get along. This also shows a lack of skills pertaining to crew resource management. The goal of CRM is to encourage each member of the crew to freely question authority not for the authority to remove the crew from the loop of making decisions. This crew was obviously intimidated …show more content…
The KLM crew was required by organizational policy to not violate flight and crew duty times that resulted in delays without facing severe penalty. The next hole in the defensive layer is the poor qualities of the KLM captain as a leader, who seemed to be fixated on meeting departure times at all cost regardless of the input received from other crew members. Pre-conditions include deteriorated weather, poor communications between the controller and the KLM crew and between the KLM crew members themselves and finally radio frequency