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The Deadliest Plane Crash

NOVA investigates the worst aviation accident of all time. Airing October 17, 2006 at 9 pm on PBS Aired October 17, 2006 on PBS

Program Description

(Program not available for streaming.) On March 27, 1977, on the island of Tenerife, two fully loaded 747 jumbo jets collided on a fog-blanketed runway, claiming the lives of 583 people in what is still the deadliest crash in aviation history. Now, almost 30 years later, near misses on the ground are the leading cause of aviation accidents, raising the question of what can be done to improve runway safety. Featuring moving interviews with the few survivors of the disaster and with top accident investigators, this program examines the fateful confluence of events that led to the Tenerife tragedy and its continuing relevance for air travel today.

Transcript

The Deadliest Plane Crash

PBS Airdate: October 17, 2006

NARRATOR: Blinded by thick fog, two fully loaded 747s race towards disaster.

ROBERT BRAGG (Pan Am Flight 1736 First Officer/Survivor): Get off! Get off! Get off!

NARRATOR: In 1977, the worst accident in aviation history killed nearly 600 people.

KAREN ANDERSON (Pan Am Flight 1736 Passenger/Survivor): It was a survival mode that kicked in, and it was just, "get out of that airplane."

KLAAS MEURS (KLM Flight 4805 Co-Pilot/From Flight Voice Recorder): And we're now...

CAPTAIN JACOB VAN ZANTEN (KLM Flight 4805 Pilot/From Flight Voice Recorder): We're going...

NARRATOR: Blamed on pilot error in low visibility, the accident was a wake up call.

JOHN NANCE (Network Aviation Analyst): I think every airline pilot knew there was something here that probably had made this an accident waiting to happen.

NARRATOR: But now, 30 years later, near misses on runways continue to occur. Technology exists to warn controllers and pilots of impending collisions, but only a few airports have it. The government's top safety bureau warns that it may only be a matter of time before a major collision happens.

MARK V. ROSENKER (Chairman, National Transportation Safety Board): We've been operating on luck. We can't continue to do that. Safety is not a lucky system; it's a system of science, analysis and fact.

NARRATOR: Are we doomed to repeat history?

AIR TRAFFIC CONTROLLER (Tenerife): Standby for takeoff. I will call you.

ROBERT BRAGG: We're still taxiing down the runway.

NARRATOR: What will it take to make our runways safer? There are lessons to be learned from The Deadliest Plane Crash, up next on NOVA.

NARRATOR: Close to the shores of Africa, surrounded by warm seas, are seven volcanic islands called the Canaries. This Spanish territory is one of the world's most popular tourist destinations.

On March 27th, 1977, a KLM 747 prepares to depart from the Canary island, Tenerife.

JACOB VAN ZANTEN: Ready for start up, in sequence, one, two, three, four.

AIR TRAFFIC CONTROLLER (Tenerife): Affirmative, we're ready on one.

NARRATOR: The huge jumbo jet taxis into position. At the same time, a thick fog gathers on the runway, cutting visibility. The pilot, Jacob Van Zanten, has logged more than 11,000 hours in the cockpit. But, despite his years of experience, he makes a terrible mistake, one that will baffle experts for decades to come. He begins his takeoff without clearance from the tower. What he doesn't realize is that another plane, a Pan Am 747, is taxiing on the same runway.

CAPTAIN VICTOR GRUBBS (Pan Am Flight 1736 Pilot/Survivor): That son of a bitch is coming straight at us!

JACOB VAN ZANTEN: Damn! Come on! Please!

ROBERT BRAGG: Get off! Get off!

NARRATOR: The crash and fire, on the runway at Tenerife, killed 583 people, making it the worst aviation accident in history. The handful who survived recall a harrowing ordeal.

ROBERT BRAGG: We had 28 people in the upstairs lounge; the lounge was no longer on the airplane.

KAREN ANDERSON: I looked in the cabin, and everything was on fire.

JOAN JACKSON (Pan Am Flight 1736 Flight Attendant/Survivor): I thought, "Oh my god, we're trapped."

SUZANNE DONOVAN (Pan Am Flight 1736 Flight Attendant/Survivor): Joan was standing there yelling, "Suzanne, take my hand."

KAREN ANDERSON: It was a survival mode that kicked in, and I was just, like, "Get out of that airplane."

WARREN HOPKINS (Pan Am Flight 1736 Passenger/Survivor): I said, "I will jump and try and break your fall."

JOAN JACKSON: I felt so responsible, because I couldn't take care of my passengers, and so helpless...and looking back and knowing that there is nothing you can do. You can't get back in the aircraft. There's no way to get in it, and it's all on fire.

NARRATOR: As the news spreads around the world, everyone wants to know: "How could such a devastating accident occur? And why would such a seasoned pilot violate such a basic rule of aviation?"

JOHN NANCE: I can't emphasize to you, enough, how incredibly seismic this accident was. This was the granddaddy—not only of accidents, in terms of numbers of deaths and the fact that it was two 747s—this was so horrific, involving the best and the brightest of pilots. We had to get inside the pilot's mind; we had to know what happened.

NARRATOR: The story of the worst accident in aviation history begins about 4 hours before the crash. Two 747s are approaching Gando Airport on Grand Canary Island, a KLM flight from the Netherlands, and a Pan Am flight out of Los Angeles.

The American plane made a stop in New York where it picked up a fresh crew. The cabin is nearly full, with 378 passengers and 13 flight attendants to look after them.

JOAN JACKSON: I was on the flight with my best friend, Suzanne Donovan. And we used to bid flights together. We could do that, because we enjoyed each other's company so much.

NARRATOR: Onboard the Dutch plane: 234 passengers and 14 crew, commanded by KLM's chief pilot, Captain Jacob Van Zanten.

JOHN NANCE: Jacob Van Zanten was the type of senior captain that all of us, as airline pilots, eventually wanted to be. I mean, this was the top of the food chain. This was the guy who was not only a family man—well respected, well loved—at KLM he was at the top of the management chain as a pilot. He was the head of safety; he was an individual who everybody at that airline looked up to. This was a fellow whose face was on most of the advertising about KLM all over the world. I mean this was the best and the brightest.

NARRATOR: Van Zanten spends most of his time training other pilots, including the man in the next seat, Klaas Meurs. In fact, it was Van Zanten who issued Meurs his 747 certification.

Of the 234 Dutch passengers, many are vacationing families, 52 children among them. Three are not tourists, but rather tour guides who live in the Canaries and are now returning to their homes.

ROBINA VAN LANSCHOT: (Tour Guide/KLM 4805 Passenger to Tenerife): I lived in Puerto de la Cruz. That's a small village northwest of Tenerife. Yvonne was traveling with me. Walter was traveling with us. It was a very nice atmosphere on board, a very relaxed atmosphere.

NARRATOR: As the two planes near Las Palmas, a drama begins to unfold at Gando Airport, when an anonymous caller warns that a bomb has been placed in the terminal.

Though the Canaries lie off the coast of Africa, they are Spanish territory. The bomb threat was the work of separatists waging a violent campaign for independence. As luck would have it, the terrorists chose this moment to act.

AIRPORT OFFICIAL: Leave all of your belongings behind and exit immediately. All passengers must leave the terminal immediately. Attention all passengers, leave all of your belongings and exit immediately. All passengers must...

NARRATOR: A few minutes after the call, a bomb explodes at Gando Airport.

JACOB VAN ZANTEN: Gando, KLM 4805 is with you now.

GANDO AIRPORT AIR TRAFFIC CONTROLLER: KLM 4805, Gando. The airport is closed.

NARRATOR: The tower at Gando radios the KLM pilot that the airport is closed. All planes are diverted to Los Rodeos airport, on nearby Tenerife Island.

This diversion could prove to be a significant problem. The KLM crew is scheduled to return to Amsterdam later that day; a long delay at Tenerife could put them past their duty time limits.

JOHN COX (Accident Investigator): Pilots are limited as to the amount that they can work in any given day. After that there's a required rest period. This is done to combat fatigue and to help reduce the likelihood of errors. In the KLM case, they were beginning to push that limit. And that is always a concern, because if you can't complete the flight, now you have to overnight yourself and, unexpectedly, all of your passengers, in a remote location that may or may not actually be able to accommodate them.

ROBERT BRAGG: Gando, Pan Am 1736. Good afternoon.

GANDO AIRPORT AIR TRAFFIC CONTROLLER: Pan Am 1736, Gando. The airport is closed.

NARRATOR: The tower diverts the Pan Am plane as well. The first officer requests permission to remain in a holding pattern until the airport has reopened, but the request is denied.

GANDO AIRPORT AIR TRAFFIC CONTROLLER: Negative, sir. I say again, the airport is closed.

ROBERT BRAGG: I think they just had so much traffic to deal with they didn't have time to even consider giving an airplane clearance to hold or whatever. So that's, that's what I assumed, that they had made up their mind that they were just diverting everyone to Tenerife.

NARRATOR: So, now, both jumbo jets find themselves heading for the smaller Los Rodeos Airport, on the island of Tenerife, half an hour away. It has only one runway, but it's the closest alternative.

JOHN NANCE: Tenerife was a commercial airport, but it was a smaller airport. It was perfectly okay to bring a 747 in there, on a diversion, but not a whole fleet of airplanes, as happened on that day. The problem was there weren't enough places to park them; there weren't enough people on fuel trucks; there wasn't enough in the way of facilities to handle this influx of passengers. And it was frustrating for every one of the aircrews involved.

VICTOR GRUBBS: Ladies and gentlemen this is Captain...

NARRATOR: Captain Victor Grubbs breaks the news to the weary passengers, who've been traveling for more than 12 hours already.

KAREN ANDERSON: When they made the announcement that we were not going to be able to land, right then, at Las Palmas, mostly I was frustrated because it had been a really long trip, and I was tired, and time changes and this and that, so I guess I would say the chief feeling was frustration and sadness that we couldn't immediately disembark.

WARREN HOPKINS: People were not happy about this because it was not a good omen, you know. It was not a good omen having this take place.

NARRATOR: For the air traffic controllers at Los Rodeos, it's bad news as well. It's Sunday. Only two controllers are on duty, and they're not accustomed to handling this much traffic.

FERNANDO AZCUNAGA (LOS RODEOS AIR TRAFFIC CONTROLLER): KLM 4805, you are number three behind the 737. Report outer marker.

JACOB VAN ZANTEN: 4805. Follow the 737, report outer marker, Los Rodeos grounds. KLM 4805.

NARRATOR: After landing, the KLM pilot allows the passengers to deplane to wait out the delay. Soon, the small terminal becomes overwhelmed by the influx of unexpected visitors, and now the Pan Am plane, ferrying hundreds more, arrives.

ROBERT BRAGG: The ground situation was a traffic jam, because, when we landed there, the ramp was so crowded with other airplanes, and we were directed to taxi down to the end of the ramp area and park behind three other airplanes.

NARRATOR: Every new plane that arrives takes up more of the limited parking space. Soon, all the taxiways are blocked. The controllers discuss how best to maneuver the planes when it comes time to take off. Their plan calls for the two jumbo jets to drive onto the runway, taxi to the opposite end, turn around and go. It's a slow and cumbersome procedure, but they have no choice.

JOHN NANCE: Back taxiing is done all the time in aviation. There is nothing particularly unsafe, difficult or strange about it. Where there are taxiway problems, and you need to use the runway to position an airplane, that's the normal way to do it.

NARRATOR: While they plan, a new problem develops. The weather begins to deteriorate, clouds roll in.

JACOB VAN ZANTEN: I'm worried we're going to get caught by this fog. All we need now is for them...

NARRATOR: The KLM pilot worries that if they remain on the ground too long, they will have to go off duty, stranding everyone for the night.

Meanwhile, back in the terminal, the tour guide, Robina, has decided to stay on Tenerife, which is where her boyfriend lives. She tries in vain to persuade her friends to stay with her.

ROBINA VAN LANSCHOT: They were making plans. You know, "We're going to have dinner here, and then we're going to have a drink there." And I just wanted to go back to him.

NARRATOR: In the end, it's love that saves Robina.

PAUL WESSELS (Robina Van Lanschot's Boyfriend): I met Robina in December, 1976.

ROBINA VAN LANSCHOT: I fell in love, and we've never been...

PAUL WESSELS: ...separated.

ROBINA VAN LANSCHOT: No, not again, afterwards.

NARRATOR: With all diverted aircraft now on the ground, the tower crew suddenly has little to do except worry about the weather and listen to a soccer match to pass the time...

GANDO AIRPORT AIR TRAFFIC CONTROLLER: Rodeos, Rodeos, Gando.

RODEOS AIRPORT AIR TRAFFIC CONTROLLER: Rodeos. Go ahead.

GANDO AIRPORT AIR TRAFFIC CONTROLLER: Gando to Tenerife A.T.C., we've just reopened.

NARRATOR: ...until word comes that Gando airport has reopened. And, at last, everyone can leave.

PUBLIC ADDRESS ANNOUNCEMENT: (DRAMATIZATION): Ladies and gentlemen, may I have your attention, please? Gando Airport has reopened. Your flights will be re-boarding shortly. Please make your way back to the gate as quickly as possible when your flight is called. Thank you for your attention.

ROBERTO ALVAREZ (Runway Coordinator, Los Rodeos): Boarding was very complicated, because, when the passengers were called for their flights, they were scattered throughout the airport, in the cafeteria or buying souvenirs. We had to go round them up, and, in fact, some passengers never did board the aircraft.

NARRATOR: While the KLM waits for its passengers to re-board the crew decides to refuel. This seemingly routine decision will have catastrophic consequences.

JOHN NANCE: As you add fuel to an airplane, even the size of a 747, you increase the amount of speed necessary for what we call "V1 and rotate," in other words to lift it off the runway. You increase the landing and takeoff distance by a certain amount. These are all very calculated figures, and, of course, you look at that before you make the decision, as a captain, on whether or not to refuel at a particular location.

NARRATOR: In order to keep the weight down at takeoff, the normal practice is to take on only the amount of fuel required. But the Dutch captain takes on 55 tons, enough to get him not just to Las Palmas, but all the way back to Amsterdam.

PUBLIC ADDRESS ANNOUNCEMENT (DRAMATIZATION): KLM 4805.

NARRATOR: Inside the terminal, all the passengers are called to rejoin their flights. Meanwhile, Robina says goodbye to her friends.

ROBINA VAN LANSCHOT: They wanted me to go with them. And they really tried to persuade me, and I tried to persuade them to stay. And, yeah, but that's, that's how it goes.

AIR TRAFFIC CONTROLLER (Tenerife) The temperature is 14 and falling.

NARRATOR: The controllers are now racing against the worsening weather. But some planes can't move. The Pan Am Plane is stuck behind the KLM which is still refueling.

AIR TRAFFIC CONTROLLER (Tenerife): 1736 there is a delay for you. The KLM in front of you is refueling.

NARRATOR: So the first and second officers decide to go outside to see if there's room to taxi around the other jet.

ROBERT BRAGG: The engineer and I went out underneath the right wing and, basically, stepped off the distance between our wingtip and the KLM 747's wingtip, and we were 12 feet short of being able to taxi easily around the airplane.

NARRATOR: For the KLM, another delay. Two children have wandered off, and the parents have gone to look for them. The flight attendants ask the runway coordinator to find the missing family.

When he locates them, he takes them back to the plane, but time has been lost and the weather is getting worse.

ROBERTO ALVAREZ: I'll never forget that. If I hadn't found them, they'd be alive today.

NARRATOR: Fortunately for Robina, she wasn't missed by the KLM crew.

AIR TRAFFIC CONTROLLER (Tenerife): Station calling to start...

JACOB VAN ZANTEN: Ground, KLM 4805 is ready for start up.

FERNANDO AZCUNAGA: 4805, clear to start.

NARRATOR: The KLM pilots start their engines one by one and prepare to go back out onto the runway for takeoff. But the fog is closing in. As the clouds roll over the runway, visibility drops from 10 kilometers down to three, in just a few minutes.

KLAAS MEURS: Approach, 4805 requires backtrack on runway one-two for takeoff on three-zero.

FERNANDO AZCUNAGA: Taxi straight ahead to end of runway and make a backtrack.

KLAAS MEURS: Roger. Make a backtrack. 4805 is now on the runway.

ROBERT BRAGG: Pan Am 1736 ready to start.

FERNANDO AZCUNAGA: Pan Am 1736 clear to taxi on runway, following the KLM.

ROBERT BRAGG: Pan Am 1736 following KLM.

Basically, our instructions were to follow KLM, to backtrack down the runway. Now, backtrack means that you're taxiing down the runway in the opposite direction of the takeoff, following KLM.

NARRATOR: The second 747, weighing 335 tons, turns onto the runway and creeps along at about 10 miles per hour. The two aircraft are on the same runway. The visibility is fluctuating, but it's still very poor.

ROBERT BRAGG: And we saw the fog bank come off of the right hill, and proceed down and stop right on the runway. So our visibility went from unlimited to 500 meters. We lost sight of the KLM airplane.

NARRATOR: The American pilots are nervous. They can't see the KLM plane, and that means that the KLM can't see them, even when it turns around. The Pan Am has to turn off the runway. But where?

It's from this moment that we know, from the voice and data recorders in both planes and from the tower recorder, exactly what transpired. The tower now confirms that visibility has dropped to 500 meters.

JOHN NANCE: There are several things you're worried about immediately, as the visibility drops. Remember, your eye to runway height is over 40 feet in a 747, and you can have a fog so thick you can't even see the runway right in front of you. Secondly, you're worrying about, when you get to the end of the runway, you're going to have legal visibility for takeoff.

VICTOR GRUBBS: Look at it out there. I mean this cloud just rolled right onto us. I don't think anybody has the minimums now.

ROBERT BRAGG: We turned our chart over and it said, "RVR minimum 700 meters visibility." So we assumed that with him just giving us 500 meters, we couldn't take off.

Pan Am 1736.

FERNANDO AZCUNAGA: Pan Am 1736, approach.

ROBERT BRAGG: Uh, we were also instructed to taxi down the runway. Is that correct?

FERNANDO AZCUNAGA: Affirmative. Taxi to the runway. Leave the runway third, third to your left.

ROBERT BRAGG: Third to the left, okay.

GEORGE WARNS (FLIGHT ENGINEER): Third he said?

ROBERT BRAGG: Three.

FERNANDO AZCUNAGA: Third. Third to your left.

VICTOR GRUBBS: I thought he said first.

FERNANDO AZCUNAGA: Leave the runway third to your left, third to your left.

ROBERT BRAGG: Left turn.

NARRATOR: Unfamiliar with the airport, the Pan Am pilots search for their turnoff. Their confusion arises from the fact that the third exit, Charlie 3, requires making a very sharp turn which would point them in the wrong direction down the taxiway. To reach the end of the runway, the next exit, Charlie 4, with a 45 degree angle, seems to make better sense.

ROBERT BRAGG: Would you confirm that you want Pan Am 1736 to turn left at the third intersection?

FERNANDO AZCUNAGA: The third one, sir: one, two, three. Third, third one.

ROBERT BRAGG: One, two.

VICTOR GRUBBS: Good. That's what we need right, the third one?

GEORGE WARNS: Uno, dos, tres.

VICTOR GRUBBS: Right.

JOHN COX: Pan Am was told to take the third taxiway. Well, "Third from what?" became the question. Was he counting the taxi where they had come out of? Which taxiway was the first one in the count? There were several turnoffs in the runway, one of which was very hard to make, because it was such an extreme angle.

FERNANDO AZCUNAGA: 1736 report runway clear.

ROBERT BRAGG: Pan Am 1736.

We couldn't see any taxiways. We couldn't see...barely, the centerline of the runway we were taxiing on, but we knew that the 45-degree angle to the left was the taxiway to take.

NARRATOR: Meanwhile, the KLM, half a mile ahead and hidden in the fog, nears the end of the runway. Back in the tower, things are becoming tense. For several minutes, they've been unable to see either jumbo jet on the runway.

JOHN NANCE: Your different airplanes that you're controlling are going to report to you precisely what they're doing and where they are; this is the theory. That controller has to maintain a clear mental lock on where these individuals are, these airplanes, at all times.

FERNANDO AZCUNAGA: Pan Am 1736, approach. Position please.

ROBERT BRAGG: 1736, just checking that.

VICTOR GRUBBS: Yeah, that's the 45.

NARRATOR: The tower asks the Pan Am plane to report its position, and it's clear from the transcript that the crew still cannot find the turnoff.

VICTOR GRUBBS: It goes ahead. I think it will take us to the taxiway.

ROBERT BRAGG: Maybe he counts these as three.

VICTOR GRUBBS: Oh, I like this.

NARRATOR: The visibility goes up and down by the minute. In the KLM, Captain Van Zanten is worried that the airport will close. There's a good chance he's going to be trapped on the ground, forced to spend the night at Los Rodeos—not an enticing prospect.

JOHN NANCE: Here's what Jacob would have been thinking about: "If I have to shut the operation down and give my guys 12 hours of rest, and myself, I'm going to have to buy outbound rooms, rather, for the passengers, that's for one day. That's going to be a huge expense. I'm going to have a 747 sitting on the ramp, where it shouldn't be, and one less bird to fly the next scheduled trips out of Amsterdam. That's going to cost us a little bit of time and money." But the most important thing, and this is true, is the embarrassment of a senior leader and being unable to make happen what he wanted to have happen.

NARRATOR: At the end of the runway, the plane begins its 180-degree turn. It's just after 5 p.m. The two aircraft are now face-to-face a half a mile apart, unable to see each other in the fog.

JACOB VAN ZANTEN: Okay, we have 700 meters visibility here now.

KLAAS MEURS: Wait a minute, we don't have A.T.C. clearance.

JACOB VAN ZANTEN: I know that. Go ahead ask.

KLAAS MEURS: Uh, KLM 4805 is now ready for takeoff. We're waiting for A.T.C. clearance.

FERNANDO AZCUNAGA: KLM 4805. You're cleared to the Papa Beacon. Climb to and maintain.

NARRATOR: Air traffic control clearance is permission to fly the route once airborne. But it's not permission to take off. That has to be obtained separately.

FERNANDO AZCUNAGA: Las Palmas, V.O.R.

KLAAS MEURS: Roger, sir. We're cleared to the Papa Beacon, flight level 9,0, right turn out 0, 4,0 until intercepting the 3, 2, 5, and we're now...

JACOB VAN ZANTEN: We're going.

VICTOR GRUBBS: No!

FERNANDO AZCUNAGA: Stand by for takeoff. I will call you.

ROBERT BRAGG: And we're still taxiing down the runway.

Pan Am 1736.

FERNANDO AZCUNAGA: Pan Am 1736, report runway clear.

ROBERT BRAGG: Okay, we'll report runway clear.

FERNANDO AZCUNAGA: Thank you, 1736.

ROBERT BRAGG: He asked us were we off the runway, and I responded back negative, we are still on the runway but we will report clear of the runway. That was the last thing I said, over the radio.

We were only taxiing at three miles an hour. Nothing in my mind would have even given me the thought that he was taking off.

WILLEM SCHREUDER (KLM Flight 4805 Flight Engineer): Is he clear then?

JACOB VAN ZANTEN: What did he say?

WILLEM SCHREUDER: Is it clear, the Pan Am?

JACOB VAN ZANTEN: Oh, yes.

NARRATOR: The die is cast. With every second, the KLM is going faster and faster. At that moment, the Pan Am begins to turn off the runway.

VICTOR GRUBBS: Damn! That son of a bitch is coming straight at us!

JACOB VAN ZANTEN: Damn! Come on! Come on! Come on! Come on!

ROBERT BRAGG: Get off!

JACOB VAN ZANTEN: Please!

ROBERT BRAGG: Get off! Get off!

When he hit us, I didn't think he'd done us that much damage, 'cause the airplane very quickly shuddered and gave a "plomp."

JOAN JACKSON: The first thing was this huge loud noise. And the only thing I could liken it to is as if each molecule of air exploded. That's the way I thought of it, afterwards. It just was so loud.

ERMA SCHLECHT: (Pan Am Flight 1736 Passenger/Survivor): At first, I thought they had gotten to us with a bomb. It came up and slammed down. The lights went out and flames came through.

KAREN ANDERSON: The minute I opened my eyes, I looked in the cabin, and everything was on fire.

ROBERT BRAGG: All the windows were gone in the cockpit. I looked out to the right, the right wing was on fire. I looked back to the left. We had 28 people in the upstairs lounge; the lounge was no longer on the airplane. It was just a big hole there. And I could see all the way to the tail of the airplane, just like someone had taken a big knife and cut the top off.

SUZANNE DONOVAN: I was staring at the door. And I yelled, "Unfasten your seatbelts; remove your shoes; leave everything; come this way." And as I stared at the door, a jagged hole seemed to open up in the roof over the door.

JOAN JACKSON: And the next thing I knew, I was outside that. And I don't know how I got out there.

SUZANNE DONOVAN: Joan was standing there yelling, "Suzanne take my hand!"

JOAN JACKSON: And I was standing above the level of the door, on fuselage rubble pieces. And I leaned down and said to Suzanne, "Give me your hand!"

SUZANNE DONOVAN: I lost Joan's hand very quickly, so I jumped. And it was about...it seemed like the leap from a second story building.

ROBERT BRAGG: The captain, he elected to jump down in the first class section of the airplane. And when he hit the first class floor, the floor collapsed and he fell down in the cargo area.

ERMA SCHLECHT: I immediately thought it was total destruction. It never dawned on me that I would make it. But I thought, "Hey, you know, do something. Don't just sit there, do something!" I just went over the seatbacks, and I am not that athletic really, but I went over three rows of seats. One man was sitting there looking like, "I need help," but I couldn't help him.

ROBERT BRAGG: When the KLM hit us, all communications stopped. The tower called, couldn't get any response from either the KLM or ourselves. There was an airplane in the holding pattern right above Tenerife, called the tower and said, "I see smoke and wreckage on your runway."

STERLING PLANE PILOT: Rodeos approach, Sterling 105. We're downwind from runway 3,0, and something's glowing on the field, looks like a fire.

FERNANDO AZCUNAGA: Come on, come on!

ROBERT BRAGG: He hits the emergency warning. After KLM hit us, he went on down the runway, and hit on the runway 1,500 feet down, closer to the tower, so when the fire truck and the ambulance came out, they got to him first.

NARRATOR: After the initial impact, the KLM continues flying for another 150 meters before slamming into the ground. The 55 tons of fuel the Dutch plane had taken on creates a massive fireball that seals the fate of everyone onboard. Not one person survives. Fire crews don't immediately realize that there is another plane hidden in the fog.

ROBERT BRAGG: No one came to us for quite a while. As a matter of fact, I remember thinking, "I wonder why somebody hasn't gotten out here to help us."

NARRATOR: For 20 long minutes, the Pan Am passengers are left to fend for themselves.

ROBERT BRAGG: The entire left wing of the airplane was covered with passengers. And it turned out there were probably 45 to 50 passengers out on that wing.

KAREN ANDERSON: I've never asked anybody how high the wing is from the ground on a 747, but it looks to be a very long ways.

WARREN HOPKINS: And I cut open my head and fractured my foot. My wife jumped after me, and she said, "I cannot walk." And I dragged her on her side for probably a block and a half away from the plane.

ERMA SCHLECHT: The motors were going full tilt, and I didn't want to get over where the motors were. So I sat down by the body of the plane. I had no comprehension, at that moment, that I would be jumping off the wing and...

SUZANNE DONOVAN: In the debris, you knew, there were trapped passengers and...people, and there was absolutely nothing you could do to help, because the airplane was collapsing in on people.

ROBERT BRAGG: When I got out on the ground, I could hear people screaming and yelling and all. Within about five minutes you heard absolutely nothing. There was no noise at all, just the air...the airplane burning. I asked one of our medical directors later on what he calls that, and he said, when you have a fire that hot and that much of a fire, it consumes all of the oxygen in the air, and people basically suffocate.

JOAN JACKSON: And I thought if we could just walk around to the other side of the plane, we would find the other passengers and our fellow crew members, which, of course, wasn't the case.

KAREN ANDERSON: My husband was sitting to my right, and I undid his seatbelt and kind of pushed him out of his seat to get him moving. And we headed for the door, and it was engulfed in flames, and there was no way to exit that way. I looked over, and at some point, someone had opened the other door, which was amazing to me. And I just yelled, "Over here," and headed toward the door on the other side, which was, again, the wing door.

NARRATOR: In her haste to get out of the burning plane, Karen becomes separated from her husband. He dies in the flames.

Later, Spanish authorities set up a morgue in one of the hangars. Five-hundred-eighty-three people died. Even today, it's still the highest death toll of any aviation disaster. And soon everyone began asking the same questions: "How and why could two state-of-the-art airliners smash into each other on the same runway?"

JOHN COX: After doing accident investigation for something over 20 years, I've never seen an accident that didn't have several pieces in this chain that had to come up just the way that they did, for the accident to occur. And this is one of those cases.

NARRATOR: Investigators from the U.S., the Netherlands and Spain slowly pieced together the improbable chain of coincidences, bad luck and questionable judgment that led to the accident.

They recognized that the bomb, the overcrowded airport and the bad weather were all unavoidable. The investigators agreed that pilot error was the cause of the accident, but the teams disagreed about how to apportion blame. The Dutch complained that the controllers in the tower used non-standard terminology and that the two men were listening to a soccer match while they worked. But the Dutch saved their strongest criticism for the Pan Am pilots who failed to turn off at the third exit due to confusion and fog.

But is that considered pilot error?

JOHN NANCE: There is no experienced air crew out there who hasn't missed a turnoff, gone someplace a few feet, at least, that they shouldn't have in an airplane, violated a clearance of some sort, inadvertently. Turning off at the wrong taxiway or not turning off is a human mistake. It was not a professional discretionary error, and that's how you have to look at it. Anybody who would try to hang an air crew for that does not understand the equation.

NARRATOR: The Spanish and American investigators acknowledged that the Pan Am mistake played a role, but they held that the main fault lay with the KLM crew, because there was one undeniable fact. Captain Van Zanten took off without proper clearance from the tower. The burning question was why?

The answer revealed a systemic problem that plagued cockpits throughout the aviation industry.

JOHN NANCE: At the time of Tenerife, none of the subordinate crew members had the authority to shut down the takeoff, had the authority to tell the captain something the captain didn't want to hear. And, on top of that, they had a clear reason to be concerned, if they insulted a captain or made the captain mad.

NARRATOR: The critical turning point came just 67 seconds before the collision. That's when, according to the KLM data and voice recorders, Captain Van Zanten first applied power to the engines. First Officer Meurs quickly reminded him that they had not yet received air traffic clearance. This was an almost unthinkable error for an experienced pilot to make.

JOHN NANCE: One of the things that Jacob Van Zanten and any senior leader in that position, would have felt, is just absolute internal horror at the fact that he had just made an attempt to start a takeoff roll without a clearance. The embarrassment level is just beyond belief. And he's just made a mistake like this.

NARRATOR: The tower then relayed to KLM an A.T.C. clearance, which is not the same as permission to take off. What happened next stunned investigators. Captain Van Zanten repeated his earlier mistake and began to apply power again. And this time, no one spoke up.

JOHN NANCE: You make a mistake; you start thinking about the mistake; you begin to make more and more errors. This is a very familiar syndrome. We call it "checkitis" in aviation. Even somebody as experienced as Van Zanten had to have a certain part of his mentality pulled away to deal with the embarrassment of this. And then, this is one of the reasons—understanding this—why the co-pilot would have opted just to tell the tower that they were rolling, rather than, once again, turning to his senior leader and embarrassing him yet another time.

NARRATOR: As they began their takeoff roll, the collision might yet have been averted if not for a terrible piece of bad luck.

First Officer Meurs told the tower that they were beginning their roll. The tower told them to stand by. At the same time, the Pan Am cockpit warned that they were still on the runway. In the KLM cockpit, these simultaneous transmissions were audible, but barely.

DAVID EVANS (Editor, Aviation Maintenance Magazine): When you want to speak in the radio, you mash down on the transmit button, and that means that if someone else is trying to transmit at the same time, it's not necessarily certain that his transmission is going to get through. And that occurred with the Pan Am jet in this accident—that their transmission that they were still on the runway only came through partially or was incomplete, at the same time that the KLM airplane had initiated its takeoff roll.

NARRATOR: It's possible that Van Zanten didn't hear either message, although the KLM flight engineer appeared to react to it.

WILLEM SCHREUDER: Isn't he clear then?

JACOB VAN ZANTEN: What'd he say?

WILLEM SCHREUDER: Isn't he clear then? That Pan Am?

JACOB VAN ZANTEN: Oh, yes.

NARRATOR: Those are the last clear words on the KLM voice recorder. The data recorder, though, suggested that Captain Van Zanten quickly realized that he was on a collision course, because he tried to take off early.

JOHN COX: The airplane is accelerating rapidly during the takeoff roll. And it's covering hundreds of feet per second, so that by the time he saw it, there was no hope that he was going to be able to stop in time to avoid the collision. That only left him the possibility of trying to fly over the top of it. And as he rotated, to try and get the 747 airborne at the earliest possible moment, it struck the tail. And there was impact marks on the runway. They only had 3 or 4 seconds to sort it out.

JACOB VAN ZANTEN: Please!

ROBERT BRAGG: Get off! Get off!

JOHN NANCE: Ultimately, the reason that that KLM aircraft began rolling down that fog shrouded runway was this was a team, but it wasn't allowed to operate like a team. So one man made a mistake and that mistake stuck.

NARRATOR: Today, 30 years later, cockpit culture is very different. Pilots are trained not only to tolerate input from other members of the crew, but to encourage it.

DAVID EVANS: There has been an effort, if you will, to flatten the authority gradient. So, even though you may have many years of experience separating the captain from the first officer, they are operating much more closely as a team, rather than as the guy in charge and his, the knight's squire, as it were, operating alongside him.

NARRATOR: But despite extensive training and heightened awareness, runway incursions—defined as any vehicle on a runway when it shouldn't be—occur in the U.S. with surprising regularity.

MARK ROSENKER: We're seeing something like 325 of them a year. That's too many. The possibilities are too great for a collision, for an accident where many deaths could be a result.

NARRATOR: Of these, as many as 25 each year are considered extremely serious. An almost exact repeat of Tenerife took place in 1999, at Chicago's O'Hare airport.

The National Transportation Safety Board produced this forensic animation which shows a Korea Air 747 being forced to climb over a China Air 747 that had blundered onto the runway. The two planes missed each other by only 80 feet.

And another, even more recently: in 2005, in Boston, an air traffic controller cleared a US Airways jet for takeoff. But at the same time another controller cleared an Aer Lingus flight to take off on a crossing runway. At the last minute, the US Airways co-pilot spotted the other plane and warned the captain who delayed his takeoff as long as he could, allowing the Aer Lingus to slip overhead.

Had the co-pilot not felt free to speak up, hundreds of people could have died. Airlines, today, extensively train pilots in simulators, not only to perform emergency maneuvers, but to condition behavior as well.

BILLY NOLEN (Safety Manager, American Airlines: One of the things we do, is take situations that involve the human factor element—crews' coordination and working together—and we say, we will be given situations to say, "Here's what happened on some flight. Now how would you have done it differently?" And...the result of which is to get crews to work better together so that this doesn't become a point of contention.

NARRATOR: But improved pilot training is only one defense in a system with as many potential failing points as there are there human beings involved.

BILL DAVIS (Air Traffic Organization Vice President, Safety Services, Federal Aviation Administration): There's 15,000 controllers, over 600,000 pilots, and hundreds of thousands of drivers that operate on the nation's airports. They're all subject to making human error. We'd like to take technology to a level that we can use technology to reduce the possibility of human error, or, if an error is made, catch that error before it becomes a catastrophe.

NARRATOR: The Federal Aviation Administration has spent millions of dollars to improve taxiway markings and lighting at airports. And at some airports, the agency has installed technology to track movement on runways, to warn controllers of impending collisions.

The N.T.S.B. insists that alerting the control tower of potential accidents is still not enough.

MARK ROSENKER: It doesn't really get us to where we want to be, which is with a redundant system that provides communication to a cockpit crew, so that they can make the final decision whether they should go across an active runway, go around, in case there is an occupied runway. That's really what we believe will prevent runway incursions.

NARRATOR: Because of those concerns, the F.A.A. is now experimenting with an improved system that warns pilots directly of possible runway conflicts. Embedded in one runway at Dallas/Forth Worth Airport, sets of bright red signals act as a kind of smart traffic light for aircraft.

When a runway is in use, the airport's movement tracking system automatically switches on red holding lights to warn taxiing pilots not to cross onto the active strip.

The Dallas experiment seems to demonstrate that the technology exists to prevent another Tenerife. The F.A.A. is still evaluating the program. Meanwhile, fewer than 10 percent of the nation's increasingly crowded airports have any kind of movement detection system at all, and the N.T.S.B. has warned the F.A.A. that the yearly number of incursions is simply too high.

MARK ROSENKER: Too long are we dealing with issues like 325 runway incursions a year. We must begin the process of bringing those numbers down. We've been lucky too long. I don't believe our luck can hold out.

NARRATOR: Today, the accident at Tenerife remains a stark reminder of what's at stake every time an airliner pushes back from the terminal. As for those who survived, each has struggled to bear the burden of that terrible day in his or her own way.

SUZANNE DONOVAN: Friends that travel, I tell them, "Make sure you know where your exit is. Make sure you read all that stuff. Know how to get out of the airplane." I mean those are important things.

KAREN ANDERSON: The loss of my husband had a tremendous impact on my life, on my son's life, on my extended family's lives. It was huge.

SUZANNE DONOVAN: Well, after the crash, I decided to start a family. I thought, "Maybe I will stay home and have children."

JOAN JACKSON: I thought, you know, "My friends have died, and if I let myself sit in this little apartment, it's going to be as if I'm curled up and died. And that's not fair to them. I can honor them best by living a life, a full life and not being afraid."

ROBERT BRAGG: I think it brought home to me how quickly you can leave this life, and how everyone should enjoy life, every and each day, as much as you possibly can.

ROBINA VAN LANSCHOT: I felt ashamed the first while. And a long, long time, I thought, you know, I wish I died, because I felt very bad.

SUZANNE DONOVAN: I was scared for quite a while after the crash, but I knew, if I flew with Joan, she would pull me out again.

Broadcast Credits

The Deadliest Plane Crash

Directed by
Chantal Hébert
Produced for NOVA by
Chris Schmidt
Narrated by
Neil Ross
Associate Producer
Andy Howard
Edited by
Dan Crow
Chris Schmidt
Camera
Yoan Cart
David Fox
Gary Henoch
Bill Kerrigan
Erich Roland
Sound Recordists
Juan Rodriquez
Dana Marxen
Bruce Santhuff
Mike Peterson
Jeff Hoien
Music
Claude Castonguay
Ray Loring
Animation
Sputnik Animation
Assitant Online Editor
Owen Williams
Online Editor and Colorist
Doug Plante
Cast - Pan Am Flight Crew
Captain Victor Grubbs
Randall Holden
Co-Pilot Robert Bragg
Paul Bandey
Flight Engineer George Warns
Mike Dineen
Cast - KLM Flight Crew
Captain Van Zanten
Michaïl Hofland
Co-Pilot Klaas Meurs
Bruce Van Barthold
Flight Engineer Willem Schreuder
Nicolas Mead
Cast - Tenerife Air Traffic Controllers
Joe Rezwin
Grégory Reznick
Consultant
Barry Davis
Aviation Consultant
Gérard Feldzer
Set Designer
Jean Marc Pacaud
Computer Graphics
Trimaran, Paris
Graphics Producer
Oliver Emery
Graphics Supervisor
Geoffrey Guiot
Producers for "Crash of the Century"
Galaxie Productions
Cineflix
Adélaïde Productions
Executive Producers for Cineflix
André Barro
Bernard Vaillot
Co-Executive Producers for Cineflix
Glen Salzman
Katherine Buck
Supervising Producers for Cineflix
Michel Rager
Léon G. Arcand
Kathryn Liptrott-Galligan
Executive Producer for BSkyB
Paul Crompton
Archival Material
ABCNEWS
Videosource
BBC Worldwide
ITN Archive
KRO Television
NBC News Archives
NTSB
Robina and Paul Wessels
RTVE
NOVA Series Graphics
yU + co.
NOVA Theme Music
Walter Werzowa
John Luker
Musikvergnuegen, Inc.
Additional NOVA Theme Music
Ray Loring
Post Production Online Editor
Mark Steele
Closed Captioning
The Caption Center
NOVA Administrators
Dara Bourne
Ashley King
Publicity
Eileen Campion
Olivia Wong
Researcher
Gaia Remerowski
Production Coordinator
Linda Callahan
Unit Managers
Carla Raimer
Karen Lally
Paralegal
Raphael Nemes
Legal Counsel
Susan Rosen Shishko
Post Production Assistant
Joshua Thurston
Assistant Editor
Alex Kreuter
Associate Producer, Post Production
Patrick Carey
Post Production Supervisor
Regina O'Toole
Post Production Editor
Rebecca Nieto
Post Production Manager
Nathan Gunner
Supervising Producer
Stephen Sweigart
Producer, Special Projects
Susanne Simpson
Coordinating Producer
Laurie Cahalane
Senior Science Editor
Evan Hadingham
Senior Series Producer
Melanie Wallace
Managing Director
Alan Ritsko
Senior Executive Producer
Paula S. Apsell

Crash of the Century © Galaxie Production / Near-Miss Productions Inc./ Adélaïde Production, 2005

A France-Canada co-production

Produced by Galaxie Production - Cineflix - Adélaïde Productions in association with Canal D, an Astral Media Network; M6; BSkyB

Additional Production for NOVA by Zerkalo, Inc.

The Deadliest Plane Crash Additional Material added © 2006 WGBH Educational Foundation

All Rights Reserved

Image

(simulation of Tenerife crash)
© Galaxie Production

Participants

Roberto Alvarez
Runway Coordinator, Los Rodeos
Karen Anderson
Pan Am Passenger
Robert Bragg
Pan Am First Officer www.tenerifecrash.com/
John Cox
Accident Investigator www.safeopsys.com/
Bill Davis
VP of Safety Services, Air Traffic Origanization, FAA www.ato.faa.gov/
Suzanne Donovan
Pan Am Flight Attendant
David Evans
Editor, Aviation Maintenance Wkly
Warren Hopkins
Pan Am Passenger
Joan Jackson
Pan Am Flight Attendant
Robina Van Lanschot
KLM Passenger
John Nance
Network Aviation Analyst www.johnjnance.com/moreabout/moreabout.htm
Billy Nolen
Safety Manager, American Airlines
Mark Rosenker
Chairman, NTSB www.ntsb.gov/Abt_NTSB/bios/rosenker.htm
Erma Schlect
Pan Am Passenger
Paul Wessels
Robina's Boyfriend

Sources

Links

Project Tenerife
project-tenerife.com/engels/index.htm
This memorial website offers articles on the Tenerife crash, photos of the flight crews and the crash site, downloadable files of official Spanish and Dutch reports, and an online forum for discussing topics related to the disaster.

National Transportation Safety Board: Aviation
www.ntsb.gov/aviation/aviation.htm
The National Transportation Safety Board oversees aviation, highway, rail, marine, and pipeline transportation safety across the U.S. On its website, find accident data, reports from official investigations, and other resources.

Aviation Safety Network
aviation-safety.net
The Aviation Safety Network provides an extensive database of over 12,200 airliner, military transport, and corporate aircraft accidents since 1943. Visitors to its website will also find crash site photos, airline safety information, accident statistics, and more.

The Human Factors Research and Engineering Group
www.hf.faa.gov
On this website from the Federal Aviation Administration, learn about human factors that might lead to aircraft accidents, read annual government reports, and find links to other online resources.

In the Cockpit
alpa.org/?tabid=187
Take an insider's look at some of the current issues in commercial aviation through the website of the Air Line Pilots Association.

Books

Fatal Words: Communication Clashes and Aircraft Crashes
by Steven Cushing. University of Chicago Press, 1997.

MAYDAY: Accident Reports and Voice Transcripts from Airline Crash Investigations
by Marion F. Sturkey. Heritage Press International, 2001.

Air Accident Investigation
by David Owen. Haynes Publications, 2002.

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