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Worksafe BC for Mind Map for the Tenerife Air Disaster, March 1977…

- - - - Both crews very knowledgeable about their job. Execution was not always correct.
      - Controllers had local knowledge of the airport and likely believed their instructions were clear and may have had some confidence in these instructions even in the foggy conditions and it was not out of the ordinary for them.
    - - KLM pilot trusted skills and knowledge and garbled radio call when requesting take off permission.
      - KLM pilot most recently spent a lot of time in simulators where there is usually a straight run to take off.
      - Controllers used to the poor weather conditions and may have been following the same processes as they usually would without acknowledging the significantly higher workload.
    - - KLM pilot expected that the PanAm had completed its back track and was off the runway based on a garbled radio communication.
      - Due to spending a lot of time prior to the accident in the simulator, KLM pilot probably expected that the controller would give permission to take off. Trusted a garbled radio call as permission.
      - Business as usual for a pilot even though the location was different than expected due to the diversion.
    - - KLM pilot focussed on leaving as soon as possible
      - Controllers focussed on ensuring all flights could leave as soon as possible
    - - Goal of both crews to get their passengers to their destination as soon as possible.
      - Meet company and legal requirements associated with duty limits
      - Meet company goals in relation to delivery of passengers on time
    - - KLM crew duty limits designed to prevent unnecessary fatigue.
      - Pilot and co-pilot of both crews able to fly the plane and monitor the instrumentations to give each other a break during flight.
      - Some checklists carried out when preparing for take off. Can assist when fatigued.
    - - KLM pilot stressed about exceeding crew duty limits
      - Minor stress relating to diverting to another airport and preparing the aircraft for the diversion.
      - PanAm and KLM crews stressed about the weather/poor visibility
      - Passengers stressed due to missing connections with other transportation (i.e. cruise passengers).
      - Cabin crew stressed when needing to calm passengers stuck in the cabin with poor airflow (and hot). Reassuring passengers with little information themselves.
      - KLM passengers (children) missing when flight re-boarded.
        
        Additional stress on the cabin crew and pilots wanting to prevent further delays.
      - Controllers stressed due to volume and size of aircraft and relative size of airport and parking space for aircraft.
      - Unclear communications by radio probably heightened stress, particularly of the PanAm crew when the KLM attempted the first take off.
      - Lack of runway centre lights may have stressed pilots slightly considering the weather conditions.
      - Controllers stressed as they had to manage a higher workload with no ground radar in very foggy conditions on a usually quiet Sunday.
    - - KLM Pilot had decades of experience flying and was a flight instructor for KLM.
      - PanAm crew all very experienced pilots
      - KLM Co-pilot/first officer relatively new to flying the 747, but somewhat experienced with other aircraft.
      - Controllers had a lot more aircraft than usual to manage.
      - Controllers had bigger aircraft than they were used to at the airport that they were required to instruct.
      - Tarmac/apron was full of parked aircraft.
      - Controllers used to the poor weather conditions and may have been following the same processes as they usually would without acknowledging the significantly higher workload.
    - - KLM Pilot approved his co-pilot on 747 assessment
      - PanAm crew jovial during delay.
- - - - KLM crew close to breaching duty limits and eager to leave as soon as possible.
      - PanAm crew do not appear to be concerned with rosters or duty limits.
    - - Workload within the cabin and cockpit similar to any usual flight
      - Additional workload of pilots due to weather conditions and poor visibility.
      - Change of airport for arrival due to terrorist bomb explosion at original destination. Required to set up planes for landing at a different airport.
      - Cabin crew required to keep plane load full of passengers updated and calm for a number of hours.
      - KLM pilot concerned with duty limits, potentially impeded thought processes - distractions/loss of focus
      - Controllers could have closed the airport until weather improved.
        
        May have been somewhat immune to the conditions as it was a regular occurrance.
    - - Get a plane load of people to their destination as safely and quickly as possible
        
        KLM pilot decided to fill aircraft fuel tanks with enough fuel to make it to original destination and return journey to Amsterdam to avoid any further delays.
        
        Addition of fuel delayed PanAm flight from taking off sooner.
        
        Airport not big enough for PanAm 747 to manoeuvre around the KLM 747.
        
        Delay by loading fuel on to KLM meant weather conditions worsened the closer to take off.
      - Pilots have very technical roles with lots of requirements throughout each step.
      - Cabin Crew required to tend to plane load of passengers for an extended period of time, after almost completing their original journey.
    - - KLM head office in some ways supervising the crew when determining if they have sufficient duty time available for their return journey to Amsterdam.
      - Although a training pilot, the KLM pilot was checked by his co-pilot when an attempt was made to take off without ATC clearance.
      - No apparent supervision of controllers in an unusual situation.
        
        Could have closed the airport
        
        Could have put more staff on to help reduce the workload.
        
        Could have waited for one plane to take off before back tracking the second.
  - - - Radio only means of communicating between aircraft and controllers.
        
        Need clear protocols for radio communication.
        
        Not followed/in place at the time.
        
        Informal language used i.e. yes rather than affirmative
        
        Generic terminology used for giving directions i.e. 'take the third exit' rather than 'take taxiway XYZ'. Reliant on local knowledge or relative position at time of call.
      - Crew communication
        
        KLM crew - communication strained between the pilot and co-pilot. KLM Pilot had domineering personality.
        
        PanAm crew relaxed with each other and clearly communicated what they were doing.
        
        Controllers believed they communicated
        clearly with the crews of both planes.
        
        Generic terminology for describing the taxiway PanAm was to exit on i.e. 'take the third exit' rather than 'take taxiway XYZ'.
        
        Confused the crew of the PanAm. Confirmed the instruction with the controller to ensure they understood the instructions communicated to them.
    - - Radio communication required for Controllers to instruct pilots
      - PanAm crew filled instructions given by the controller as they understood them.
    - - Insufficient signage at airport to designate taxiways and runways.
      - Would have been difficult to see even if it was present due to the poor visibility (fog).
    - - No issues with the controls/control labels determined from the official investigation/s.
- - - - Foggy runway/airport
      - Warm inside cabin of PanAm as passengers and crew generally stayed on board without air conditioning/air flow through the cabin.
      - Temperature and wind speed ok
      - Visibility at minimum or below minimums for take off at times
      - Patchy fog (variable visibility), moving quickly
    - - Noise in the cockpit of the KLM aircraft due to engine power/thrust increasing just prior to and during take off
      - Radio heterodyne interfering with radio transmissions
      - Controllers supposedly listening to soccer match on radio at time of delays and instructing movement of aircraft.
    - - Vibration of the aircraft during taxi and take off
    - - Poor lighting due to cover of fog. Low visibility on runway prior to take off.
      - Runway centre line lighting not operational
      - Aircraft taxiing lights on, but obscured due to fog/poor visbility
  - - - Airport built in area prone to fog
      - Radio system not designed to block simultaneous transmissions
      - Runway centre line lights not operating
      - Terminal too small to cater for the amount of passengers diverted
      - Airport apron too small to cater for large amount of aircraft and larger aircraft i.e. Boeing 747s
      - Single runway at the airport, required planes to back track down the runway rather than taxiways as would usually occur.
      - Taxiways not suitable for large aircraft. If PanAm took the turnoff that they though the controller was talking about, they would not have been able to make the turn - 747 turning circle a lot larger than the usual aircraft that landed at the airport.