1 Problem

worst runway collision kills 583

What Problem(s) Runway collision March 27, 1977 was a difficult day for the aviation industry. Just after noon, a bomb exploded at the Las Palmas
When Date March 27, 1977 passenger terminal in the Canary Islands. Five large passenger planes were diverted to the Tenerife-Norte Los Rodeos
Time 5:06 PM Airport, where they completely covered the taxiway of the one-runway regional airport. Less than five hours later, when
the planes were finally given permission to takeoff, two collided on the runway, killing 583, making this the worst accident
Different, unusual, unique Large number of flights diverted due to bombing, at the time (and second now only to the September 11, 2001 attacks in the US.)
dense fog
Where Facility, site Tenerife-Norte Los Rodeos Airport Possible solution:
Standardized
Unit, area, equipment Two Boeing 747s communications

Task being performed Taxi/ takeoff For a free copy of our Root Cause Analysis Template in Microsoft
Confusing
Excel, used to create this page, visit our web site.
instructions
Impact to the Goals
Safety 583 killed (61 survivors on PanAm flight) Evidence:
Discussion used the
Customer Service Compensation to families of victims Investigate Problems. Prevent Problems. Pilot believed word "takeoff" but
Houston, Texas 281-412-7766 ThinkReliability.com had clearance was not approval
Property/ Equipment Both airplanes destroyed for takeoff
AND
Labor/ Time Rescue, response, investigation
Simultaneous
Radio
calls from both
Solution: interference
planes
2 Analysis Effect Cause
One plane
attempting Did not hear
takeoff AND
radio Radio
Evidence:
See same cause
transmission interference
Safety Goal from plane
"From the investigation it can be established that Impacted
AND
the accident was not due to a single cause. The
misunderstanding arose from generally used
procedures, terminologies and habit-patterns. The 583 killed
Limited visibility Heavy fog
unfortunate coincidence of the misunderstanding Unaware of
with a number of other factors has nevertheless presence of
Customer Compensation Evidence: Runway
other plane
resulted in a fatal accident." Service Goal to families of visibility ~300 m
Impacted victims
AND
- Comments of the Netherlands Department of Civil
Aviation on the Netherlands Aviation Safety Board Possible solution:
Install ground radar
Investigation Report Runway AND
collision of 2 AND
Property/ Possible solution: Airport not
planes
Both airplanes Crew Resource equipped with
Equipment Management
destroyed ground radar
Goal Impacted
Flight crew
concerns not
addressed

Rescue, 5 large planes Bomb/ bomb

Labor/ Time diverted to threat at Gran
Cause Mapping is a Root Cause Analysis method that captures basic response,
Goal Impacted Tenerife Canaria
cause-and-effect relationships supported with evidence. investigation
Taxiway
Cause Mapping 3 Solutions unavailable for
Planes parked
on taxiway
AND
Problem Solving • Incident Investigation • Root Cause Analysis taxiing
Tenerife not
After the tragedy, the airport was upgraded to include ground radar.
built to
What's the Solutions that impacted the entire aviation industry included the use of Second plane
Step 1. 1 Problem Problem? backtracking on AND
accommodate
English as the official control language (to be used when communicating large planes
runway
between aircraft and control towers) and also prohibited the use of the word
Why did it "takeoff" unless approving or revoking takeoff clearance. The potential that
Step 2. 2 Analysis happen? Second plane
action by one of the other crew members could have saved the flights aided did not turn off
in the concept of Crew Resource Management, to ensure that all flight crew ?
runway when
What will be members could and would speak up when they had questions related to the instructed
Step 3. 3 Solutions done?
safety of the plane. Evidence: Turn may Copyright ThinkReliability 2015
not have been
possible for aircraft