The Deadliest Plane Crash

[Spinner]

Nova is presenting an hour long program on the Tenerife crash in 1977. As always, check your local PBS listings.

http://www.pbs.org/wgbh/nova/planecrash/

[KJ]

Ironic that was, the world's worst air crash, caused by THE most experienced Stan/Eval pilot in KLM. There is a lesson to be learned there.

[Spinner]

I've read a lot of reports and analysis of the crash. I didn't know the Captain on the KLM flight held that position with the airline.

Just goes to show how fragile complex systems can be. The aircraft are complex, certainly, but the human factors and the computer between the ears are what make it all tick.

Interesting that we've have had, in the last 5 years, one of the safest periods in US aviation history. At least until the Comair crash in Lexington, KY in August. And, as is often the case, an error in human judgement is the suspected cause.

A link to an interesting book on the role of human error in powered flight.

http://books.google.com/books?hl=en&lr=&id=4JTJOFpvAK8C&oi=fnd&pg=PA1&sig=ZzZB7rE5Ueb3TG6f1eGdrYiWCmM&dq=%22Wiegmann%22+%22A+Human+Error+Approach+to+Avi ation+Accident+Analysis:+...%22+&prev=http://scholar.google.com/scholar%3Fq%3Dauthor:%2522Wiegmann%2522%2Bintitle: %2522A%2BHuman%2BError%2BApproach%2Bto%2BAviation% 2BAccident%2BAnalysis:%2B...%2522%2B%26hl%3Den%26l r%3D

[Ergogirl]

I've read a lot of reports and analysis of the crash...

The book you linked to...... It's funny you mentioned it. I'm at a conference right now on this very subject (human factors) and will be attending talks tomorrow where both authors will be presenting their recent works. Wiegmann is branching out into medical human error and Shappell is dabbling in highway safety these days.

Other excellent books on disasters in complex systems are: Normal Accidents by Charles Perrow and Inviting Disaster by Chiles. For a less technical alternative, there's always the Set Phasers To Stun series.

Some of that stuff is scarrier than The Exorcist. :eek:

[Spinner]

The book you linked to...... It's funny you mentioned it. I'm at a conference right now on this very subject (human factors) and will be attending talks tomorrow where both authors will be presenting their recent works. Wiegmann is branching out into medical human error and Shappell is dabbling in highway safety these days.

Other excellent books on disasters in complex systems are: Normal Accidents by Charles Perrow and Inviting Disaster by Chiles. For a less technical alternative, there's always the Set Phasers To Stun series.

Some of that stuff is scarrier than The Exorcist. :eek:

I read Perrow's book a few years back, in fact shortly after I left my position at O'Hare. I saw first hand how simple human mistakes could add up to a disaster.

It's usually the little things which, taken alone, probably wouldn't add up to any problems. In the Tenerife disaster, the KLM Captain was trying to get back in the air for a couple of reasons, both of which directly lead to the accident. First, he wanted to get airborne and complete the last, short leg of the trip prior to being subject to the mandatory rest period. The airline would have lost money, and he was aware of this. That affected his judgement because he was almost too eager to get it airborne even under those conditions.

So, trying to avoid taking a "delay", coupled with the time restrictions on the crew and the cost the airline would have incurred because of that, colored his judgement as he was revving those engines. Taking on the extra fuel and the Pan Am Captain's failure to turn off the runway earlier were contributing factors, but without that aircraft trying to take off, there is no accident.

It's the little things. I can't remember the title, but there's a book out there that gives detailed CVR transcripts and descriptions of accidents that have occured, many of which I may have heard about previously only in passing. Some unbelievable gaffes, but only in hindsight. A couple of examples:

A fatal airline crash because a ground crew that washed the aircraft placed masking tape over all the pitot tubes, and the involved plane subsequently took off over water with absolutely no guidance or airspeed reference from their instruments. They were doomed the moment the plane rotated off the runway.

An Arrow Air cargo flight out of Miami, in which the clamps that held a pallet securely in place were not locked down completely, leading to a domino effect on take off in which one pallet pushed back into the pallet behind it, in turn knocking all the other pallets toward the rear of the plane, throwing the W&B off and leading the DC-8 to crash tail first with an angle of attack approaching 60 degrees.

The list goes on and on.

[Typhoon]

Thanks for the heads up, Spinner. Last night on very late Discovery Channel was running its show on the Teneriffe crash, complete with very detailed graphics. I imagine that the show will be rerun.

While I was taking a walk the other day I ran into a guy who did work for the government investigating the Lockheed Electra crash at Logan Airport in October 1960 that killed 62 people. Turns out that the plane was brought down by a flock of flying birds, and the man I spoke with had to count the gull population around the airport....

[Ergogirl]

A fatal airline crash because a ground crew that washed the aircraft placed masking tape over all the pitot tubes, and the involved plane subsequently took off over water with absolutely no guidance or airspeed reference from their instruments. They were doomed the moment the plane rotated off the runway.

Aeropero 603.

I think this was the one where several of the passengers survived the watery crash only to drown because they inflated their life vests before exiting the aircraft and became trapped against the bulkhead as the fuselage sank. :(

[Spinner]

Here's another from that same CVR book that really stood out, involving a Southern Air Transport C-130 that crashed on takeoff.

The aircraft came into a CONUS military base to take on some extremely dangerous cargo, loads of ordnance and explosives destined for who knows where. The flight crew parked the aircraft, and after they left the area the ground crew started the loading process, which for a C-130 at the time included going into the cockpit and positioning and locking the yoke with some device so that the elevators were in the up position, in order to facilitate loading.

So the ground crew gets all this stuff loaded, and the flight crew returns to start their pre-takeoff checklist, failing to notice that the device was still affixed to the yoke. Apparently, it was a fairly unobtrusive widget and their were no notification placards or warnings placed on the yoke. They get the plane going and taxi to take off, and the elevators are locked in their highest position as they begin their take off roll.

According to witnesses, when the plane reached its takeoff speed it shot into the air and went almost vertical, stalled out and fell back to the runway and exploded on contact. Based on the CVR, the pilot realized, too late, that the yoke lock was in place. By that time, there was nothing he could have done to correct his situation.

I started working at the airport about a year and a half after the valujet crash, and I couldn't believe what some of the forwarders were still trying to get away with, always trying to shave a buck off their costs by circumventing regs regarding the shipment of hazmat items. They'd bury some really dangerous stuff deep in the middle of their shipper built pallets, trying to keep from paying the costs associated with me giving their DG shipments the seal of approval. That's always in the back of my mind when I board a plane. I'm not worried about mechanical failure as much as human error, much of it not even associated with the flight crew.