The Tenerife runway disaster: pilot error and human factors analysis

Human/Machine Interface Systems Application: What Can Go Wrong?
In early 1977, two jet airliners collided on a runway at the Tenerife, Canary Islands international airport, causing 583 deaths in the worst air disaster in aviation history (Constable, 2019). The purpose of this paper is to provide a review of the relevant mainstream media and scholarly literature to identify the antecedent events that contributed to 1997 runway crash of KLM 4805 and Pan Am 1736 at Tenerife in the Canary Islands. A brief description of this aviation disaster and the main impediments that hindered the decision-making of those directly involved in the crash is followed by a prioritization of these impediments to identify the most egregious and an explanation concerning how these proposed actions might be translated into the everyday actions of a successful corporate leader. Finally, a summary of the research and important findings concerning the crash of KLM 4805 and Pan Am 1736 as well as their implications for corporate leaders are provided in the conclusion. Review and Discussion Background and overview
Nestled off the northwestern coast of Africa, the Spanish-owned Canary Islands are famed for their pristine white sand beaches and the destination is widely regarded as a veritable tropical paradise for visitors. For example, according to Harvey (2002), “The Canary Islands enjoy a climate known as primavera eternal [“eternal spring”]. Mariners once called them Las Islas Fortunatas, the Fortunate Islands, and every winter, millions of tourists flock there” (p. 178). The largest island in the Canaries, Tenerife, is the home of the capital, Santa Cruz de Tenerife, as well as the site of the worst aviation disaster in history which is discussed further below.
When Edwin Murphy first propounded his now-famous “Murphy’s Law” (e.g., “Whatever can go wrong will go wrong”), he might have had the events that transpired on March 26 and 27, 1977 at Los Rodeos Airport on Tenerife in mind (Tan, 2013). Indeed, most people have experienced situations where their lives would have been permanently changed if they had left their homes a few minutes earlier or later, and the exigencies of the human condition mean that there is always the potential for human error. Although each of the several actions taken by ground control and the two pilots involved contributed to the crash to varying degrees (see prioritized list below), most investigators and researchers agree that pilot error stands out as being the most responsible for causing the worst aviation disaster in history. The prioritized list of the several factors that contributed to the March 27, 1977 crash at Los Rodeos Airport is as follows: Pilot error; Muddled instructions from air traffic controllers, Pilot fatigue (the captains of both aircraft were anxious to get airborne, particularly Captain Grubbs who was unfamiliar with Los Rodeos Airport and was fatigued from having already flown for 8 hours); Limited ground visibility (i.e., about 1,000 feet) with deteriorating weather; Malfunctioning runway lights at Los Rodeos Airport; Los Rodeos Airport was overcrowded; Violent militants detonated a small bomb at the larger Las Palmas Airport on Gran Canaria the day prior resulted in air traffic being diverted to Los Rodeos Airport which is comparatively much smaller; and, Because the apron at Los Rodeos was already full of airplanes, overworked and tired air traffic controllers started directing incoming flights onto taxiways which intersected with the main runway. While the above-listed prioritization is highly subjective and any one or more of these events and actions could have been more culpable in causing the crash than another, it is reasonable to posit that their cumulative total exacerbated the potential for pilot error to the point where the tragic collision because inevitable. For instance, one aviation analyst reports that:
Despite the various factors feeding into the disaster, the official inquiry laid the entire blame on van Zanten. The veteran pilot's most egregious sin, caused either by impatience or miscommunication, was to take off without having received clearance from the tower. Had van Zanten waited, the worst aviation accident in history would never have happened. (The worst air disaster ever, 2018, para. 4).
Moreover, because human error on the part of the aircraft pilots and ground control authorities was largely responsible for the early 1977 aviation disaster, the potential for a recurrence is always present. In this regard, one aviation industry analyst emphasizes that, “It is ironic that the deadliest accident in aviation history took place not in the air but between two planes on solid ground. The tragedy was certainly an anomaly, but the risk of on-ground accidents, called ‘incursions’ in the airline industry, remains very real” (Carrison, 2017, p. 4).
In an effort to identify opportunities for improvement, an explanation concerning how each of the above-listed actions the pilots of both aircraft should have taken to avoid the crash and loss of life and how these proposed actions might be translated into the daily actions of a successful corporate leader is provided below. Application of Causative Tenerife Crash Factors to Successful Corporate Leaders 1. Pilot error: The commanders of aircraft and vessels are referred to as “captain” for good reason. Just as they receive the majority of the credit for a successful flight, the “buck also stops” with these individuals when things go wrong irrespective of the circumstances. Similarly, successful corporate executives understand and appreciate the fact that that they are accountable not only to their organization but to their peers and subordinates as well. At sea and in the air, the captain’s word is absolute law because the safety and welfare of the crew and passengers literally depends on it.
Further, even senior members of the flight crew, including the co-pilot, are typically reluctant to point out pilot errors even when disaster is clearly looming because of their personal career interests. For example, according to Carrison (2017), “The co-pilot, who aspires to sit in the pilots chair one day, must rely on positive reviews from the captain and is understandably loath to question his/her decisions, especially if the two individuals have not flown together previously to establish a working relationship” (p. 4). In a corporate context, the same tendency is evident when subordinates fail to caution against strategies or policies they know to be ill-advised. In this regard, Thomas (2014) points out that corporate executives’
. . . positional authority and yes men/women acolytes give [them] a false sense of security regarding their knowledge, skills, and abilities [and] the fact that people acquiesce to their demands does not make them any more of a leader than being six foot seven makes an individual a professional athlete. (p. 55)
Of course, in the corporate world, this tendency to avoid questioning suboptimal leadership can result in major business failures, but people rarely die as a result. In an aviation context, it is clear that this tendency can be deadly, but the implications for corporate executives are also severe when they fail to perform their due diligence and maintain adequate oversight (Thomas, 2014).
2. Muddled instructions from air traffic controllers: Just as English is the lingua franca of the aviation industry, so too has English become the common language of international business. The increasingly rapid globalization of the world’s marketplace has likewise introduced numerous language-related constraints to communication that have adversely affected commercial operations in numerous ways (Bambrick-Santoyo, 2013). Indeed, idiomatic English is fraught with ways that foreign business practitioners may completely misunderstand or misinterpret what is actually being communicated (Hambrick-Santoyo, 2013). Therefore, it is imperative for corporate executives to stay on message, keep their communication content simple and straightforward and avoid jargon, adages and sayings when communicating with people from other countries whose native language is not English (Handrick-Santoyo, 2013).
3. Pilot fatigue: Although chronic fatigue and the resulting burnout are perhaps best known in the health care profession, the same outcomes can affect business executives in any industry. For example, according to Wharton (2009), “More than half of white-collar workers regularly suffer from stress-related mood disturbances such as headaches and migraines, insomnia, neck and lower back tension, more than a third of them suffer from chronic fatigue, and nearly 40% experience stress-related skin disorders” (p. 73). Clearly, business executives that are overworked for whatever reason (i.e., personal motivation to succeed, excessive corporate demands) will not perform at their maximum levels, and practitioners that ignore their work-life balance run the risk of a wide array of health care disorders as well as a shortened professional career (Wharton, 2009).
4. Limited ground visibility: The ongoing global coronavirus pandemic has underscored just how difficult navigating periods of uncertainty in the business world. Countless small and even larger firms have been forced to shut their doors, many of them permanently, due in part to the inability or unwillingness of corporate leaders to accept harsh realities and continue with a business-as-usual approach even in the face of imminent disaster (Lewis, 2009).
5. Malfunctioning runway lights at Los Rodeos Airport: Although there are no exact parallels between this causative factor and the corporate world, this factor can be equated with the above-described limited ground visibility in that corporate leaders may lack all of the information they need to proceed with a given course of action and to do so anyway invites disaster (Zakaria, 2006).
6. Los Rodeos Airport was overcrowded: In virtually any setting, overcrowded working conditions are widely recognized as a contributing factor for accidents as well as diminished employee morale and productivity (Roy, 2017). In sum, corporate executives owe a “duty of care” to their employees (as well as federal law) to ensure that workplaces are free of hazards and are safe for human occupation and work (Roy, 2017, p. 73).
7. Violent militants detonated a small bomb at the larger Las Palmas Airport on Gran Canaria the day prior resulted in air traffic being diverted to Los Rodeos Airport which is comparatively much smaller: Here again, while there may not be any exact parallels to this factor in the corporate world, corporate executives with multinational firms must remain vigilant concerning the potential for civil unrest in the countries in which they compete in order to prevent unexpected disruptions to their commercial operations (Green, 2013).
8. Overworked and tired air traffic controllers started directing incoming flights onto taxiways which intersected with the main runway: Just as white-collar professionals frequently suffer from fatigue and burnout, so too can other professionals and blue-collar workers that are engaged in high-pressure occupations that demand constant careful attention and unwavering reliability (Sayeed & Kumar, 2010). Indeed, aviation is not the only high-stakes industry and the decisions that are made by burned out employees in numerous other settings can likewise result in severe human and economic consequences (Sayeed & Kumar, 2010).