Video Transcript: Learning from the Tenerife Disaster: Latent Conditions

John Nance, pilot, aviation analyst for ABC News, and advocate for patient safety

Jacob, this particular day, is a very upset guy. The reason he's upset is because he's had to divert to a place he didn't want to go. See, the chief pilot has to fly every now and then, just like the director of the medical staff has to stay current, and he's gotten out and gone in a 747. He's taken this charter down to the Canary Islands, and he's going to turn around pick up another group of passengers, take them back to Amsterdam, then he’ll get back to the office and somebody else will fly the airplane on.

Except it's not working that way. Murphy has gotten in the works and there's been a bomb threat over Las Palmas, which is the main airport of the Canary Islands, so he's had to divert with several other airplanes to another airfield with a slightly higher altitude, with only one runway — it's kind of short, and it’s fog-bound today. It’s not really fog; It’s clouds blowing across the runway. But it's just the same.

He's had trouble getting his fuel. He's had trouble getting out of there, and he's about to run out of the thing we call “crew duty time.” This is the maximum amount of time that an air crew may remain on duty before we've got to put them to bed to get them some rest. I know this is a completely foreign concept to health care.

Anyway, Jacob’s an upset guy this day, because he's finally gotten his airplane started. He has 10 minutes to get this huge 747 to the end of this fog-bound runway and get off the ground without running out of crew duty time. And here's the penalty if he runs out. He's got to put everybody to bed at Las Palmas, buy $30,000 worth of hotel rooms and delays, and it's going to be very embarrassing.

He wants to go, and as they get the airplane down the field, they have to taxi down the runway about halfway, because there are no taxiways stressed for a 747 in the first part. Then he has to turn around, get on the taxiway, come to the end, turn around, line up with the runway, they can only see about 300 yards into the fog, and as they line up, the first officer who was very senior at KLM but very junior to Jacob Van Zanten, has never flown with Jacob before, and the second officer who's very senior at the airline as a second officer and flight engineer, but very junior to the first officer, who's very junior to the captain … you get the hierarchy.

As they get in position, the first officer and co-pilot sees the captain’s right hand coming forward on the throttles with these four huge JT 90 engines, 50,000 pounds of thrust a piece, and he knows that they don't have a clearance to take off. On top of that, they don't have what's known as an air traffic control clearance to actually go over to Las Palmas, and he turns toward his commander with wide eyes and says, “Sir, we don't have a takeoff clearance.” And Jacob Van Zanten pulls the throttles back, and — in the inimitable fashion that all of us who qualify as airline captains learn — he says, “I knew that. Get the clearance.”

The first officer punches the button, talks to the tower, asks for the clearance. The clearance is read to him, he reads the clearance back.

We have a little linguistic disconnect here, because the guys in the KLM cockpit speak Dutch, that's their native language, and yet they're communicating by radio in a thing we call “aviation English,” which is kind of a stylized version of English.

The fellow the tower speaks Spanish because this is a Spanish possession. He is trying to communicate in another language, aviation English, and there is even an air crew on the field moving around out there, who, according to my British friends, don't speak English at all — Pan-American. I'm told we speak American — we don't speak English.

At any rate, there is a linguistic disconnect, so when the first officer is finishing his read-back and notices with increasing horror that the captain's hand is once again coming forward on the throttles, they have now the air traffic control clearance but they still don't have the physical clearance to take off. These are two separate clearances required.

By the way, this guy is not a dummy, this is not a dumb individual, this is you or me sitting in that right seat. This is everybody in this room who has ever been in a position to see a senior individual doing something for the second time, and you got by with it first. You were well-treated when you pointed it out the first time. Do you really want to tell them again that they're fouling up?

He would like to find another way to do it, so the first officer, knowing that the captain is starting the takeoff roll without permission, keeps his finger on the transmit button and says, “And we are at takeoff, KLM 1422.”

The problem with this is that it doesn't make sense in aviation English. We are at takeoff, but as we all do as human beings, we fill in the blanks. Don’t we? You expect to hear something, and it's close, so you just go ahead and fill in the blanks.

We are at takeoff, we are in take-off position. Yeah, yeah, that’ll work, that's what he means, we're going to take off position. However, there's something wrong, and the tower controller is not really satisfied with this, and the controller presses his transmit button and says “OK. Stand by, KLM. I will call you.”

But before he can get the second part of that phrase out, somebody else who's worried transmits and the two transmissions cancel themselves out and the only thing heard in the headsets for the KLM crew is the word “OK.”

“Set power!” says Jacob. “We go!” Now the first officer's attention is entirely skewed to serving his commander, as this big jet begins to roll forward into the fog. Five knots. Ten knots. Twenty knots. There’s another radio transmission out there someplace on the air patch, and the first officer and the captain are too busy with takeoff roll to really pay attention to it, but the second officer/flight engineer, the guy who sits sidesaddle, hears this, and it worries him, and he leans forward at 35, 40 knots, and says, “Is he not clear then? That Pan-Am?” Fifty knots. Fifty-five knots. Sixty knots. “What?” says Jacob. “Huh?” says the first officer. Sixty-five knots. Seventy knots.

Now in a more timorous voice, second officer leans forward and says, “Is he not clear then? That Pan-Am?” Seventy-five knots. Eighty knots. “Yes!” says Jacob, angrily, unhappy to be interrupted in the middle of his take-off roll. “Yes!” echoes the first officer, and the second officer sits back, shuts up, and says no more.

Ninety knots. One hundred knots, 105, 110, 112 knots. They finally come out of the wall of fog and they can see ahead. What they can see is the worst thing an airline captain could possibly imagine. Another airplane sideways on the runway, right in front of them.

Pan-Am had not left the runway yet. Van Zanten pulls the yoke into his chest as hard as he can, the airplane’s nose comes off the ground, and it beds the tail in the concrete, making 50 yards of sparks. As the big bird begins to lift off the ground it’s 25 knots too slow, and yet he leaps it off the ground, and for a moment it looks like he's going to make it.

The huge Pan-Am logo slides past the left side of the peripheral vision of the cockpit. The nose gear passes safely over the back of the Pan-Am, but the body gear and the wing gear don't make it. They bite through the back of the structural integrity of the other 747. Its wings fall to the ground in flames. It comes apart. KLM’s undercarriage ripped away from it, and it falls back to the runway in flames, and within 30 seconds, 572 human beings lose their lives.