Deadliest-Ever Aviation Accident | KLM Flight 4805 | Pan Am Flight 1736

two Jumbo Jets 583 people the deadliest air crash of all time this was a nightmare beyond all expectation if I messed this up I could actually lose my license blame soon falls on One Pilot stand by for takeoff I will call you why would he ignore those instructions but as investigators sift through all the evidence we are now at takeoff whoa whoa whoa what just happened there the disaster in tenar grows more and more mysterious why didn't they get off where they were told these are the top Guys these are the the best in the business how could this happen [Music] sunjet 282 proceed directly to Runway backtrack and hold Los rodeos airport on the Spanish island of tenar is busier than it's ever been VA 783 hold short of the runway and standby for taxi clearance the controllers are swamped Scandinavian 1420 you are cleared for takeoff Sterling 7392 you are next in line Al T ala 69 right turn heading 040 [Music] goodbye a few hours ago dozens of flights were diverted here after a terrorist bombing shut down a large airport in nearby Las Palmas it's a single Runway airport with a single parallel taxiway and because of a terrorist event in the region um they had much more traffic than I'm certain that they uh would normally see Sterling 7392 taxi to the runway and exit at taxi way Charlie 3 they were dealing with aircraft that had been delayed for a good part of the day for now there was a sense of urgency to to uh to get them uh and safely on their way with so many planes parked on the taxiways the controllers instruct departing flights to taxi along the airport's only Runway to get into position for takeoff one of the planes waiting to get to Las Palmas is PanAm flight 1736 must be getting close sure hope so ready for the beach 39-year-old Robert Bragg is the first officer after we got to Las palas we were supposed to have a day there and then fly the airplane to Paris and have a Dale and then back to New York so it was supposed to be a very good trip his captain is Victor grubs flight engineer George Wars completes the highly experienced crew Pan-American World Airways was not only a Pioneer but they were the one we all looked up to tremendously those of us who wanted to be pilots and who later were always had that fantasy that we might someday fly for panamerican so they were the crem to La CRM for so many many decades the PanAm crew is ready to get back in the air but they can't taxi to the runway a km 747 has stopped in front of them to refuel we were about 12 ft short of getting around them we're all on the same radio I asked him how long would it be for him to finish feling he said about 45 minutes you're trying to get your passengers where they want to go and now km wants more fuel and it's just one of those things it gets frustrated these irritations are small but at the end of a long day they began to add up not even a sandwich it's been a long day for the 378 passengers on board the PanAm airplane the flight started in Los Angeles before stopping in New York and now in tenar Reef they had been on there airplane 12 13 hours so they were getting tired the passengers have no idea how long the delay will last km was our big concern and he we found out his fueling would be finished Del km 4805 be finished refueling requesting clearance for startup the km aircraft is finally ready to roll both 747s should be back in the air soon soon Clipper 1 1736 requesting star clearance I said okay PM is ready to start also Clipper 1736 you are clear to start okay frear checklist [Music] please ladies and gentlemen the flight deck once again I'm happy to say we've been finally cleared to get moving we should have you in the air in about 15 minutes from [Music] now the Canary Islands lie off the west coast of Africa tenar is one of seven in the Spanish archipelago the mountainous island is famous for constantly changing weather can't see anything out there a fog Bank rolled in and uh visibility went down to to almost zero Clipper 1736 cleared taxi into the runway following the 747 from km Clipper 1736 to expedite uh the the departures of both km and PanAm they taxied both on the runway at the same time to put them in a position where they would be ready for uh a departure he said uh follow km down a Runway backtrack make a exit to get around back of kale Li so that's what we were doing once they get in the air the flight to Las Palmas should only take about 25 minutes km 4805 how many taxi ways did you bu pass I think we just passed Charlie 4 now okay the km 747 will be the next plane to take off at the end of the runway make 180 and Report uh ready for ATC clearance first officer Bragg is unfamiliar with the airport he checks a Runway diagram to help find their turning okay that's this one right here close ahead it's going to put us on the taxi way as they taxi they listen to the tower controller tell the km crew ahead of them what to do after departure you are clear to the Papa Beacon climb to and maintain flight level ner0 right turn after takeoff Roger clear to the Papa Beacon Light level 90 right turnout we are now at takeoff okay uh stand by for takeoff I will call you and we're still taxing down on the runway Clipper 1736 Pap Al 1736 report Runway clear okay we'll report when we're clear thank you the PanAm crew will be turning off the Runway in just a few more yards but now something's wrong first officer Bragg can see a plane through the fog I think he's moving now looked up and there he was coming down the runway it was where obviously he was moving because his Landing lights were shaking look at him that idiot's coming so km too get off get [Music] off Captain grubs tries to steer clear of the oncoming km but it's bearing down on them at nearly 200 M an [Music] hour he had lifted off the run I could see his rotating Beacon underneath get off get off get off get off get off get off and then I ducked and set a real quick pair got to help he misses us the unimaginable collision between two Jumbo Jets has turned a Runway antenna Reef into a disaster Zone I open my eyes first thing I noticed all the Wonders were gone and it looked like somebody had taken a big knife and just cut the whole top of the airplane up get up get out that's when I decide it was time to leave it's a 45 foot drop onto solid concrete and it just jumped right over I didn't even think about it when I hit I rolled on the ground and looked around and discovered I wasn't hurt some passengers in the shattered cabin of the PanAm have also survived they're desperate to get off the plane their plane was totally burning there are Flames probably 200 ft High an opening in the fuselage offers the possibility of Escape but there are no emergency slides the long drop to the runway could be fatal with the plane engulfed in flames it's the only way out we're going to have to jump I thought the airplanes was going to blow up and I yell out and start jumping and they did only 61 people from the PanAm flight survive the cockpit crew is alive but 335 others are dead on the km flight there are no survivors 248 passengers and crew have been killed all told the disaster claims 583 lives it's the deadliest aviation accident of all time 583 people with only a few getting out on PanAm this was something that we really had not contemplated when we started building bigger airplanes nobody ever thought what if we lost two of them in a collision on the ground this was a nightmare beyond all expectation the next morning investigators from Spain the Netherlands and the United States are on the scene we didn't have a whole lot of experience with 747s crashing at that point so for an accident investigation standpoint it was going to be as big a deal as you can get PanAm clearing the runway km on its takeoff ru someone messed up they face a huge task trying to untangle the chain of events that led to this catastrophic Runway Collision the search for the black boxes begins immediately the recorders could hold important details about what was happening in both cockpits voice recorders in this case were vital you had two airworthy aircraft coming together on the runway so the events leading up to that you know were were key it was busy controllers had to get almost 50 planes off the ground in just a few hours investigators know that Los rodos airport has no ground radar to help controllers track planes at a a busy location it's unusual for a controller to have to work without ground radar it increases the stress a little bit in the tower there's no question that the small airport was dealing with more traffic than un usual was it too much for controllers to handle did they make a fatal mistake a visit to the tower is the obvious Next Step we've never been that busy and uh okay well the planes were parked here and here they had to use the runway to taxi into position one at a time they were actually having to park aircraft on the taxi way the only taxi way that they had and uh therefore kind of De from their standard operating procedures and and anytime you do that unfortunately um risk uh things get a little bit riskier so I instructed km to taxi to the foot of the runway make a 180 and wait for takeoff clearance at the end of the runway make 180 and Report uh ready for ATC clearance and a couple of minutes later he reported that he was in position here km is ready for takeoff waiting for ATC clearance when km had turned around at the end of the runway and was in position for takeoff we call that uh lineup and wait so they are waiting for takeoff clearance which will equal a clear Runway and then I had PanAm move up the runway right behind the km Papa Alpha 1736 report Runway clear okay we'll report when we're clear it's true we were busier than we ever been before but we were managing we were getting the job done it's becoming clear to investigators that the cause of the tenar tragedy goes beyond a busy airport controllers had a lot to do but they were not overwhelmed there must have been other factors at play in accident investigation we learned a long time ago that there is never ever just one cause and there are multiplicity of moving Parts on this I couldn't actually see what happened a thick fog had rolled in visibility was almost zero by then this particular airport had a unique characteristic in that um it was high enough so that you would get actually clouds rolling in across the runway Alm 4805 how many taxi ways did you passy the controller is looking out the window could not see any aircraft that were taxing either on the taxiways or on the runways and instead had to rely solely on uh Transmissions from the pilots to report whether or not they were clear of the runway investigators know that if the controller couldn't see the airplanes through the fog his instructions to the pilots would have to be Crystal Clear they gather recordings from Air Traffic Control perhaps the tapes can paint a better picture of what really really happened that was the key to the whole investigation where were the aircraft on the runways and what was being said along their path down the runway get off get off get off history's deadliest air crash is leading newscasts around the world the pressure for answers is not about to let up we knew we had a tremendous task on our hands to solve this accident all right let's start with the km nearing the end of the runway 502 investigators want to know if the tenie controller said anything to the KLM or PanAm Pilots that could have led to the Collision km 485 how many taxi ways did you pass they listen to the recordings from inside the tower I think we just passed Charlie 4 now okay just passed Charlie 4 right here km Captain yakob van zanton and his first officer clous mes taxi up the runway in thick Fog by the time that the main Island airport at Las palus reopened and everybody was getting ready to go it was down to about 700 to 900 yards visibility and that's just right at minimum at the end of the runway make 180 and Report ready uh for ATC clearance okay km was told to proceed to the end of the runway turn around and wait what was the pan mlight told to do Clipper 1736 leave the runway uh 31 on to your left whoa what did they just ask him to do I'm sorry say again please leave the runway the Third third one to your left okay uh taxi down the runway and leave the runway at the first intersection on the left is that correct negative the third one the third one whenever we look at the question of whether or not the air traffic controllers in the tower the two gentlemen on the tower we're giving clear instructions you got to remember we have kind of a a linguistic problem here because these were two Spaniards who speak Spanish as their native language attempting to speak an aviation English to an American Crew and to a km Dutch crew he's on an active Runway and he doesn't know if he's being told to get off here here or maybe here there seemed to be some confusion with as to what accent uh they were supposed to take and um I have a feeling part of that had to do with the Accents in B maybe I'll ask him again would you confirm that you want Clipper 1736 to turn left at the third intersection it takes an extra effort but the controller eventually makes himself understood the third one sir 1 2 3 the third one third the controller's accent may have been another complicating factor for pilots in an unfamiliar airport on a very busy day but for investigators it's not enough to explain the crash they need to keep digging 1 2 3 this is where they were told to get off and they clearly understood but they moved past C3 why why didn't they get off where they were told the PanAm plane taxied past the third exit why did it stay on the runway for more insight investigators examine the geometry of the turn the PanAm Pilots were asked to make that leads to a surprising discovery so we have a 148° turn here followed by another one here leaving the runway at the third intersection would have have required two very sharp turns both tighter than 90° that's practically impossible 747 is a beast this is a big big airplane you just can't turn it on a dime so a crew is going to always be reluctant an experienced crew especially like PanAm to to take a turn if it doesn't look logical to them and this one did not look logical to them all right so the Collision happened here so he obviously passed C3 and was headed for C4 instead of leaving the Runway at an exit that required two very difficult turns the PanAm crew headed for the fourth exit it was further along the runway but provided a much easier turn if you see C4 it's the only taxi way going off the Runway to 45° angle the other C3 would have not done what we need to do I can see how that would definitely have induced the the the panic M crew to think that Charlie for was the exit that they were supposed to turn at in the fog the km crew would not have been able to see that PanAm 1736 was taxiing past the C3 exit as they waited for takeoff instructions from the controller Alm is ready for takeoff awaiting ATC clearance the first clearance they were asking for was a uh a air traffic control rout clearance which tells uh Pilots how to get from the the airport that they were at tenar Reef to their destination airport the air traffic control recording suggests the km crew knew the correct procedures and was following them you are clear to the Papa Beacon clim two and maintain flight level ner0 right turn after take sounds fine Roger clear to Papa Beacon flight level 90 right turnout we are now at takeoff okay stand by for takeoff I will call you it's kind of a verification between the controller and the pilot that they are doing what they should be doing he's telling the tower he's in takeoff position but he's been told to wait for takeoff clearance so why does he start to takeoff roll investigators are mystified nothing on the tower recording can explain why the km Crews started down the runway before they were cleared to do so big question then was you know once you get over the the horrific nature of it and say how could this happen at the crash site there's New Hope of finding some answers investigators have recovered the black boxes the voice recorders were key to the investigation that gave us a insight into what was going on in the respective cockpits they can only hope the new evidence will be enough to finally solve the mystery of the worst air disaster the world has ever seen we've located the CVR the investigation into the tenar disaster shifts to the Washington headquarters of the national Transportation safety board investigator Dennis gry has painstakingly matched up the cockpit voice recordings with the known movements of both planes Okay let's listen to the pan now in this case fractions of a second mattered so it was important that we had those recorders synced up so you could hear it and you could have precise measurements of when things were said yeah that's that 45 there that's this one right here the next one is almost a 45 goes ahead it's going to put us on the taxiway the PanAm cockpit tape confirms that the crew was having a hard time figuring out where to leave the runway they're passing C3 and no one sees them did the km crew think the PanAm plane was already off the Runway keep it going what the tape reveals next suggests the answer is no we are now at takeoff and we're still taxiing down the runway Clipper 1736 both crews are using the same radio frequency km should have heard first officer brag report his location that's why I said we're still on the runway and we will report clear the runway Pap Al 1736 report Runway clear okay we'll report when we're clear thank you Crystal Clear for all to hear you're still on the runway yet km continues to take off Captain van zanton is a highly experienced pilot with more than 11,000 hours in the air what led him to believe the runway ahead was clear and that he had permission to take off it just seems so alien for the crew to make that mistake I mean these These are the these are the top Guys these are the the best in the business he lands just after 1330 investigators turn to the km voice recording for answers perhaps something said in that cockpit can explain the incomprehensible decision to start down the runway we landed here at 138 yes I know that but we have to start from 7:00 that's when be checked in you're trying to recreate the cockpit environment why certain decisions were made why things were said the time limit is 10 hours of flying withus an amplitude of 13 hours that's the fun stop over the recording reveals that the captain is worried about work hours if the crew exceeds their Duty time they'll be forced to cancel the flight and that means probably $3 $40,000 of hotel rooms for the outbound passengers for they're not going to be able to carry back that night it is a bit of a logistical nightmare especially in an out station in a foreign Place Dutch Regulators have also recently tightened the rules governing flight crew Duty time a Dutch pilot can now have his license revoked if he exceeds the legal number of hours the crew left Amsterdam at 9:00 in the morning they still have to get their passengers to Las Palmas pick up another load of passengers and get back to Amsterdam before the clock runs out if I messed this up I could actually lose my license we certainly wouldn't want that well if we baiting we might as well refuel and reef km 4805 now requesting refueling at apron van santon's concern over Duty time explains why he decided to refuel while in ten Reef he was going to do everything in his power to to make sure that he could you know complete the flight within his legal Duty time limits but then a short time later the airport in Las Palmas reopens to all Aircraft Las Palmas has reopened you may ask for start up in clearances at your discretion and Van zanon's plan backfires refueling takes much longer than expected and now he can't move until it's done when Las palus reopened here he is sucking on a fuel hose instead of starting the engin are moving this is Clipper 1736 requesting startup clearance van zanon's decision has a huge impact on the PanAm flight as well the gaym beside you has requested a refuel and it doesn't look like you're going to get by him the panamerican 747 they didn't have enough wing tip clearance you got to be kidding me Roger tenie Clipper 1736 the other captains were unhappy with him because he was the cork in the bottle the refueling delay means the km crew now has only 2 hours until they're grounded half hour to taxi half hour to get there an hour to swap passengers and get back in the air it's tight and guess what the weather's getting worse km 485 you are clear to taxi to the runway the question facing investigators now is did the rush to get off the ground in worsening weather cause the km crew to jump the gun so he taxis to the end of the runway and does his 180 we know this from the tower tapes can we hear it from that point please body gear disarmed Landing lights on checklist complete investigators hear more evidence that the captain of KLM flight 4805 may have been in a rush see throttling [Music] huh wait a minute we do not have at no I know that go ahead and ask it was obvious that uh time was an important factor in the km Captain's decision making he wasn't going to waste any time once he got to the end of the runway km is ready for takeoff waiting for ATC clearance so he requests ATC clearance we about a minute from the Collision when the first officer asked for the clearance he was asking for the air traffic control clearance completely separate from the clearance to actually roll this 500 600,000 lb monster down the runway you are clear to the Papa Beacon climb two and maintain flight level ner0 right turn after takeoff what investigators hear next answers many of the questions plaguing this investigation yes brother clear to the Papa Beacon let's go Che us FL level 90 right turn out we are now a takeoff okay whoa whoa whoa what just happened there play that again please the controller is providing instructions for what to do after takeoff you are clear to the Papa beon clim two and maintain flight level ner Z right turn after takeoff yes but the captain reacts as if he's actually been cleared for departure they get a clearance from Air Traffic Control uh that that contains the word takeoff and and that confirms for them that everything is the way it should be when in fact everything was not Roger clear to the Papa let's go check thrust before his first officer has finished reading back the instructions Captain van zanton is already on the role flight level 90 right turnout we are now at takeoff investigators now know what the Dutch first officer meant by at takeoff he's reporting that he's actually taking off not that he's ready to take off unfortunately in this case um it meant they were taking off from the km uh perspect perspective and for the air traffic control uh perspective they were hearing we are a take off position but for investigators there's something about the radio exchange that still doesn't make sense according to the tower transcripts the controller advised him to stay put okay uh standby for takeoff I will call you why didn't the km crew follow that clear instruction to stand by give me Pam at 1706 that's when PanAm reports on the same frequency that they're still on the runway and we're still taxiing down the runway Clipper 1736 hold it [Music] there why would he ignore them the cockpit recordings continue to baffle investigators until they hear another critical moment on the km tape we are now take off [Music] okay that's what he heard it's a stunning Discovery fight level 90 right turnout we are now at takeoff okay the two warnings to stay put were never heard in the KLM cockpit the Tower and the PanAm flight both made their critical calls at the exact St same moment okay and we're still taxing down the runway call Clipper 1736 the simultaneous Transmissions produced a 4-second squeal in the km cockpit we are now at takeoff okay the crew heard only one word okay unfortunately uh this happen um during that pause after the controller says okay for KLM they had no opportunity to hear the controller staying standby for takeoff nor were they able to hear because they were speaking at the same time the PanAm crew reporting that they were still on the runway so what's next there's one final transmission recorded in the km cockpit Pap Al 1736 report Runway clear it should have alerted the crew that another plane was still on the runway okay we'll report when we're clear thank you only the flight engineer seems to have understood it is he not clear then what did you say is he not clear then the panican oh yes the pilots ignore his concern and miss their last chance to avoid a disaster that will claim 583 lives oh damn [Music] it [Music] vcan should not have moved without explicit clearance you learn that in probably the first or second lesson in aviation do not take off unless you get a clearance investigators dig into the career of Captain van zanton they're looking for any anything that might explain why an experienced pilot would violate such a fundamental rule this guy was a superstar they learned that van zanton was one of km's top Pilots he was the face of the airline the director of flight safety and head of the flight training department How could a human being with so much intelligence so much capability and and experience and position and the director of safety how could he fail like this [Music] investigators suspect that in an odd twist the captain's elevated status may have played a role in the tenor disaster back in those times everyone had an awe of the captain if you will his Word was God his word was unquestioned if he has that kind of authority it's it's less likely for someone uh his Junior in this case the flight engineer and the first officer to challenge anything he [Music] does okay we'll report when we're clear thank you is he not clear then what did you say is he not clear than the panon oh yes the conversation in the km cockpit leading up to the accident seems to support that notion but van anon's esteemed status doesn't explain the most troubling question of all why did he believe it was safe to take off in the first place logically you should make extra clear that hey we're taking off is the runway clear investigators search desperately for an answer and come across a stunning detail in the captain's flight log it could be the final piece of the puzzle this was his first flight in 3 months records show that van zanon's cockpit hours had dropped dramatically in recent years he was spending most of his time in a simulator training other Pilots the simulation is interesting because when you spend a lot of time as an instructor in a simulator it's an artificial environment that we try to make as real as possible okay checklist complete let's go let's R flight simulators do a remarkably good job at recreating the experience of a real flight but there is one very important element missing there is no air traffic controller in a simulator this Focus was on training um and there was this difference in the way you treat Air Traffic Control Communications in the training environment versus the real world okay let's go trust V1 here we go take off tust go take okay let's go take off thrust tust go all the time he spend in the simulator works against him climb two and maintain flight level ner Z right turn after take Roger cleared to the Papa Beacon let's go check for us Jacob van zon's attempt to take off without a clearance resulted from his time in the simulator and and that he kind of reset himself he was his own clearance Authority in the [Music] simulator and then two separate Radio Calls that should have told him that PanAm was off the Runway can each other up okay3 the world's deadliest Airline accident is now all but inevitable I think he's moving look at him that idiot's coming basically we had a captain who wanted to get off the ground as rapidly as possible oh damn it the weather was not cooperating and he was about out of crudity time and in a situation like that the human mind our carbon based brains tend to jump a few cogs so to speak get off get off get off get off get off get off he had a gun cocked and loaded by various factors and he was the one that pulled the trigger but you have to take them all in connection the investigation into the collision at ten Reef results in dozens of recommendations few Aviation accidents have triggered a greater number of significant changes that's what began to be the seed of training for what we later call crew resource management where we said to the captain we're on to you bub you're a human being you can make mistakes even when you have no intention to and even when you're completely qualified km and other airlines transform their training methods for captains helping them become more responsive to their crew mates even the most senior and the most highly trained individuals can make mistakes and we need to rely on the resources of all the crew members to compensate for that you are clear to the Papa Beacon climb to and maintain flight level ner0 right turn after takeoff the accident also changes the very language used by controllers around the world controllers don't use the word takeoff uh unless they actually uh mean and intend for the aircraft to be doing just that taking off instead they will substitute the word um after departure uh turn right heading 04 Z or something to that effect those 583 people those those people did not die in vain we have learned those lessons they changed the whole face of Aviation [Music] safety

Channel: Mayday: Air Disaster

Views: 146,320

Keywords: Mayday series episodes, Mayday: Air Disaster, Pan Am vs KLM collision, Tenerife Airport disaster, air disaster investigation, air traffic control errors, aircraft accidents, aircraft collision analysis, airline history disasters, catastrophic air accidents, disastrous plane emergencies, fatal plane crash, flight emergency reenactment, fog related plane crashes, revealed aviation disasters, tragic air crashes history, tragic aviation documentary, tragic flight reconstruction

Id: XngSuycbGHI

Length: 42min 36sec (2556 seconds)

Published: Mon May 06 2024