Term Project Crisis Management Teensier Planes Crash Case Study Table of Contents Contents Page Abstract History Key Discussion Question 1 References 1352123 Abstract - 9 Conclusion and Recommendation The Teensier Disaster is a well known event among the aviation industry for being the worst alarm accident in human history. A Dutch KILL 747 and an American Pan Am 747 crashed Into each other at a Spanish airport In the Canary Islands resulted In 583 death and a extensive media coverage on the Dutch, American and Spanish subjects.
The disaster was investigated and studied by the International Air Transport Association (DATA), the International Civil Aviation Organization CIAO and researchers as a model for human errors in the airplane system that proved vulnerable to crisis. The disaster was summarized as a combination of human and technical errors although the investigation pointed out communication inaccuracy as the sole cause for the tragedy.
Attention error, perception error, response communication error, poor decision making and an insufficient airport all contributed to the crash. This disaster has great impact directly and indirectly to the stakeholders such as two national airline companies, the cities and their families, the airport employees and the Spanish government, as the country where the accident took place. Therefore, this disaster Involves the aviation industry In three different countries, laws, languages and also local political Issues.
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Right after the disaster, both airlines and Spanish government has to deal with several sensitive issues including the crash survivors and victim, body identification, releasing information to the public, sorting financial responsibility under the pressure of high level of media coverage and time limit. Since the event, international aviation organizations and Lorene business have worked hard to put together new regulations, crisis prevention and response plans that will stop salary events from happening. The Teensier crisis is marked as one of greatest change in aviation approach to crisis training.
It introduced anticipate crises thinking, personality and attitude test; on-board crisis plan, checklists, crisis drills and Crew Resource Management programs (CRM) as well as reinforced the strictest laws on international language and communication code used in the industry. The each stakeholder group (airline companies, passengers, Airport Air Traffic Control) to prepare for crisis. Advance communication systems. Anti-blocking device (BAD), effective safety demonstration and Rare-language are the main recommendation. The paper also discussed post-crisis restoration of the environment, infrastructure and services.
In addition, similar cases from Thailand that was created by similar errors like the political protest that Page | 1 closed down Sanitarium Airport in November 2008 and the 13TH that crashed at Tribunal international airport, Nepal in 1992. It can be concluded that the accident encouraged the aviation industry to finally address its vulnerability and flaws in ultimate areas of errors that can rise a series a contraction to a great tragedy. Accordingly to CIAO, Teensier Disaster became a required model of case study explored in present and future aviation training classes.
Page | 2 History: Teensier Disaster The Teensier disaster happened on March 27, 1977 at 17:06:56 local time at Los Rodeos Airport on the island of Teensier in the Canary Islands, Spain. On that day two of Boeing 747 crashed on each other, the disaster caused the highest number of fatalities of any single accident in aviation history. The two planes involved were the 47 airbuses of Pan American World Airways Flight 1736 (the Clipper Victor) under the control of Captain Victor Grubs, and KILL Royal Dutch Airlines Flight 4805 (the Iris) under the command of Captain Jacob Velveteen van Canteen.
Both were taking off on the only runway of the airport, the KILL flight crashed into the Pan Am aircraft taxiing in the opposite direction on the same runway. From the picture red line refers to KILL airline which trying to back taxi and take off. Pan am airline can be seen as blue line which was suppose to taxi in number 3 but it was continued until number 4. In fact both planes need to arrive in the Lass Palms Airport Spain. However, a terrorist bomb exploded in a florist's shop on the Lass plasmas terminal.
Airport authorities had been warned so although the bomb damaged the inside of the terminal, suddenly the civil aviation authorities at Lass Palms closed the airport because the political terrorists might have a chance for setting out the second bomb. All the flights that were scheduled to land at Lass Palms need to be cancelled and diverted to the smaller surrounding airports. At Teensier, the airport consisted of one runway and one major taxiway parallel to it, as well as several small taxiways connecting them. The control tower staffs were also underage | 3 qualified for their English skill.
Moreover, there are heavy fogs that prevent KILL to without permission from control tower due to serious timing rule of KILL airline, which the airline has to be on time. Therefore, KILL made a 1800 turn to take off while Pan Am 1736 was also following the KILL aircraft on the same runway. However, the pilot was not clear what the tower had said to them. Only a few minutes after KILL collided into Pan Am with catastrophic consequences. Other aviation disaster cases with the similar communication cause was 13TH case on 31 July 1992 when Airbus 10 from Thai airways was due to land at Tribunal international airport, Katmandu, Nepal.
There was misleading communications from language problem between pilot and traffic controller as well as the bad weather condition. The captain of TAG 311 asked for permission to turn left, but upon receiving no reply to his requests he"s announced that he was turning right and climbed the aircraft to flight level 200. The flight went through a 360-degree turn, passed over the airport, and crashed into a steep rock in a remote area of the Lang tang National Park at an altitude of 11,500 feet. To sum up the causes of both this and Teensier cases can be include as the communication breakdown and weather condition.
Page | 4 Key Discussion Questions 1 . What were the major communication problems [issues with your chosen crisis? First of all, "communication" means the process of transmitting and receiving ideas, information, feeling and message. Communication"s barriers include language, psychological, physical, and general in this case the most communication problem occur in this crisis is no doubt human communication factor which include attention error, perceptual error and response error. From the accident it is clear that the breakdown in communication led to a critical mistake. Attention error was one of the causes that make the KILL pilot unable to pay attention to TACT tower as much as he can. Since KILL captain was seriously concern about punctuality because it matter to his career. Therefore, he pay attention to the timing more than safety this make KILL plane took off without being making the status clear and did not heard the air traffic controllers instruction to stand by for takeoff even he know that the Pan Am aircraft may still be taxiing. 2) Perception error The bad weather condition including heavy fog and clouds covering the field.
The perception was one of the barriers that to allow both 2 planes to see clear runway. 3) Response Communication error. Due to language and misunderstanding The KILL co-pilot told the TACT tower and stated they were "ready for takeoff' and then also stated they were "waiting for our TACT clearance announce. " However, the tower responded by telling the crew what route they were to take after takeoff and, from it, used the word "takeoff. " They did not directly indicate that takeoff clearance had been given, but the use of the word seemed to confuse the KILL crew more.
KILL said, "ready to take off' to mean that the plane was already starting forward and getting ready to take off. However, the tower mistaken it to mean the plane was stand by at the end of the runway awaiting clearance for takeoff. After that the pilot made a short statement of "we"re going. " again, adding to the confusion that the plane was now cleared for takeoff. On the other hand, the Panama flight was taxiing back down the runway. They had passed the exit number 3 and were heading to outnumber 4 exit which in the wrong position.
This cause by non-standardization of calling the exit Page | 5 number. When TACT call that third exit, Panama did not know it number three exit or in order of third exit. Panama"s captain heard that the KILL flight was getting ready to take off they try to tell to the tower to inform that they were still taxiing down the runway. However, it was at the same time the KILL captain indicated that they were "going. " 2. Who were the major stakeholders which group had the most influence on communication to the stakeholders and what were the consequences of this influence?
The major stakeholders in this crisis include Panama airline, KILL airline, the passengers of both airline (both victims and survivors), relative of victims, crews, TACT tower and Spain government. The airlines would be considered as the major takeover that was affected from the disaster the most because after the crisis cost the lives of 583 people the airline have to face with infamy situation from the public. According to the investigations from black box, the conversations between pilot and TACT tower found out that the cause of the accident was consider to be pilot error.
It shows that captain has under-qualified in terms of accuracy and safety. This is the direct effect to both airline companies. First of all, after the accident the airline and government should provide the details to victim"s relatives such as who were among the survivors and victims. Later, the airlines should show that they"re concern and ready to take responsibility of the accident. From this crisis, both airlines, firstly need to revise their safety policy. Aviation is the service that should consider safety above all else.
The airline company should revisit all the policies for the cockpit crews to make sure that the rule is efficiency enough. They should study the disaster in detail and remarked that it would not happen again. In addition, Airline should be honest to communicate with stakeholders especially relative of passengers and survivors. The companies should show the responsibility such as care treatment and mutation. Post-crisis, the airlines should provide necessary information that needs to be made known to the stakeholders.
For example the cause of the accident, number of victims, aids from the company, the plan for avoids accidents in the future. The important things are to be honest by telling the truth. Nevertheless, one of stakeholders in this crisis that should take action to communicate with survivors and their victims relatives is Spain government. They should take responsibility for the crisis since the cause of this accident was originally came from the bombing from he freedom-fighter movement for independence set the bomb of the Canaries Page | 6 Archipelago at Grand Canadian airport.
In summary, the major stakeholder that had the most influence on communication are the airline companies. The airline companies stakeholders, the key idea that they need to keep in mind is to be honest and give clear information. Otherwise the crisis situation may have gotten worse and hard to handle. 3. Discuss the political issues facing the stakeholders and what problems these may cause 1) Different Nationality Airlines; KILL and Panama American are different commonality airlines, KILL is from Netherlands and Panama American is from the United States. It evidently shows that none of the companies want to take the blame for this disaster.
However, the result from this crisis is due to the fact that both of them used noon-standard phrases. 2) Third-Country Airport; Spain was in the condition of an under-standard airport location because the country was facing with civil war problems and many reckless political issues therefore, the service and the safety of the airports should be taken as one of the top priorities when compared to another safety issues. 3) Local Political Crisis. The political issue that stakeholder in Teensier crisis faced was due to the effect from the bomb exploding at Grand Canadian airport.
This better-facilitated airport supposed to be the landing airport for Panama American and KILL airlines. The movement for independence set the bomb and autonomy of the Canaries archipelago had set off the bomb. However the bomb did not killed anyone at Grand Canadian airport but it was the beginning of the disaster that cost more than 580 of innocent passengers" lives. No one could imagine the political chain-effects it had on that day. It is no doubt that political issue has a powerful effect on the country. The political issues seem to be the part of many crises.
There are many times that politic up-heaving is related to the aviation. Let me give you one of the closest example in Thailand when yellow shirt (People's Alliance for Democracy) Protest at Submachine International Airport. On the November 2008, the yellow shirt members dressed in yellow blocked the two ends of the road in front of the terminal building of Submachine international airport, in order to prevent the landing of the prime minister's flight. As a result, this event affected all the travelers in the airport as well as the inbound and age | 7 outbound flight.
In that situation there were explosions outside of the passenger terminal several people were injured. In conclusion, the political protest and violence issues do not only affect the politicians and people in the country but also many innocent people who is consider as one group of stakeholder from the crisis as well. Moreover, the conflict can lead to the large and terrible accident as Teensier disaster. Government should be able to control all situations. Especially, when the crisis involves or takes place in international presences such as airport locations.
Since, for any countries, tourism areas such as airports are the crucial point of country"s image, economic and reputation of the country. 4. Discuss the victim groups and comment on the impact of the crisis on these groups. This crisis are 1) the passengers 2) the airline staffs 3) the two airline companies and their reputation and 4) the Teensier (Spanish) Airport. Let"s begin with the passengers and the airline staffs. Out of the two airplane crashes, more than 560 people were killed and only 63 survived from the Pan Am airplane.
None of the passengers from KILL flight lived. The result is due two main factors, firstly because he KILL plane was at the point of taking off at full speed. After it collided into Panama, the impact caused the KILL to burst up in flames in midair. The chance for survival was low for both the airplane crews and the passengers. Secondly, Panama plane was only taxi-ins on the runway and their captain had made a quick and instinctively decision to turn the plane out off the way as soon as they saw KILL flight heading towards them.
While the decision did help save the lives the pilots and some of passengers, more than half of the people on the American plane were killed. After he crisis, several teams were working together to assist Page | 8 these victim group. On the Spanish part, due to the dense fog, their airport fire department was prevented from seeing the clear vision of accident and spent the crucial moments of the time taking out the fire on KILL plane before they noticed the Panama. As the news reached the mainland, the Spanish military was later flown in to help sort the American and Dutch passenger bodies as well.
However, this was an unprepared situation for a small airport like Teensier and had caused delay in rescuing the victims. For example, the airport only has two fire engine trucks, unfinished construction sites, and other forms of incomplete facilities to support the time of crisis. Feedbacks and new updates between the passengers and their families in their countries also took quite a lot of time to communicate as well since the incident took place in 1977 and the communication technology was"t advance enough.
On the other hand, once the news reached KILL headquarters in Amsterdam, Netherlands worked immediately to prepare an empty Boeing 747 and members of The Dutch Emergency Identification Staff (RITE) to pick the survivors and identify the burned bodies at Teensier Airport. They reached the location in four hours and were able to be grand permission to enter the disaster scene and identify their Dutch victims. The next day, the company sent in 4 dentists from Amsterdam to help identify the hardly recognizable bodies by teeth examination.
The Dutch company and their team were able to accomplish the difficult task of identifying and separating all the Dutch victims from the American and placed them into coffins within the timeshare of the Spanish law. The law at time stated that the body of any foreigner must be secured in the closed container by 48 hours of accident. Therefore, after the first-step procedure, the bodies of the victims were flown back to Amsterdam where over hundred medical researchers and staff worked on to uncover further details.
As all of the victims were burnt, the staffs must work against the time before the dead bodies reaches an "ante mortem" phrase, which make them harder to identify. In the end, the company was able to recognize all 248 victims. This swift action and extensive care the company took with this group of victims and their family later helped KILL restored their reputation with their own stakeholders. 58,000 to $600,000 US. Dollars. Without it, KILL reputation may have worsen as when the event unfold, Captain Jacob Velveteen van Canteen of KILL was the main person responsible for this worst disaster in aviation history.
The Panama Company team was less successful in their handling of the accident. Because the American medical team arrived much later at Teensier, they din"t received permission to identify the victims at the scene of the accident, so many important information were lost along the way of returning the bodies back to the United States. Out of the 335 Page | 9 American victims, they only managed to identify 65 percent of the victims. As a result mom of the passengers" families din"t receive closure to the investigation they need. However, the company"s pilots were not the cause of the tragedy.
As for the Teensier Airport of the Canary Islands, the crisis caused a huge pressure on the control tower and its staffs in for the management of the crowded airport. After the crisis, investigations point to the non-standard phrases the control tower used with both of the aircraft as well as the ineffective radio transmission between all parties as well. Further investigation pointed out that the Spanish control tower crews have been listening to a football match on the radio. However, the claim was never confirmed back by the airport.
From our secondary sources research, there was no clear information and news update to how the Spanish airport and authorities directly handled the post-crisis negative impact on them. 5. Communication Strategies: a. Was there a crisis management plan in place and if so, how was it communicated to the stakeholders? Before and after the crisis. It is evident that crisis can occur at any time in any industry. Therefore, most major international companies and organizations usually have either a crisis prevention plan or a crisis response plan at hand.
Crisis management is also very important to the airline business because while scientifically stated that air travel is the safest way to travel, Airplane disasters received enormous media attention and often result in long period of negativity toward the particular airline involved. Therefore, in the subjects of aviation safety, the industry has developed two main organizations like The International Air Transport Association (DATA) and The International Civil Aviation Organization (CIAO) that deal with providing an international standard on air travel safety, air transportation regulations and laws.
DATA, founded in 1945 in Havana, Cuba, is an international industry trade group of is an international industry trade group of airlines which has its headquarter in Montreal, Canada. The same goes for CIAO. However, their executive offices are located in Switzerland at Geneva Airport. For DATA, the association has more than 240 airlines Page | 10 members around the world. DATA schedules and manages these members international air traffic over 150 countries around the world.
In terms of crisis prevention and response, DATA has set an international standard and assigned "three-letter" and "two-letter code" to airports and airlines to prevent location countersigning. DATA also created "DATA Dangerous Goods Regulations" which is studied and exercised by all the airline and airport employees to recognize and deal disasters for example, terrorist bombs, hi-Jacking, weapons on boards and other unforeseen dangers from occurring. CIAO, is an organization founded by the United Nations in 1947.
The CIAO Council develops safety practices which are adopted by airline and airport staffs when faced with a crisis or an in-flight emergency. They also standardize "air navigation, infrastructure, flight inspection, prevention of unlawful interference, and facilitation of border-crossing procedures for international civil aviation". Moreover, CIAO established the protocols for air accident investigations and air transport safety. Therefore since the sass aviation industry has been developing and standardizing crisis management plans for their airline and airport members.
Pilots, cabin crews, control tower and ground staffs from different nationality, background and different languages work together towards the same procedure which gives the air passengers a confirmation on air security and safety. However, these regulations are concentrated on preventing technical errors and remonstration errors. Before the Teensier Airport disaster, the communication codes and aviation technical language between each sector of the industry were not the focus.
Regulations and practices that will minimize and eliminate communication and human errors became the top priority for DATA and CIAO only after this horrifying accident occurred in 1977. B. What were the communication errors, before, during and after the crisis? What would you have done differently? The Teensier disaster happened mainly because of the communication errors and misunderstanding between three touch points; 1) KILL cockpit 2) Panama cockpit and ) the Teensier control tower.
The communication error occurred during the length of approximately 8 minutes accordingly to the investigation"s transcript of the two cockpit"s communications with the Teensier control tower. On March 27, 1977, the KILL and Panama airplanes are both ordered to divert from the main Grand Canadian Airport in Spain due to the Page | 11 terrorist bomb explosion. They both landed on Teensier and is faced with an over- crowd airport as many airlines were also being diverted there. The weather condition was bad with heavy fog which prevented any plane from taking off and blinded the Sino from the control tower and cockpit as well.
In 1977, with no advance aviation technology identification of the location and name of the aircrafts are solely done by radio transmission. After waiting for the fog is lift up enough for departure, the KILL and Panama were both taxiing down the runway to turn around for takeoff. A non- standardize communication phrase from the control tower staff told Panama to leave the runway by saying "third to your left" without using the correct route name like "CO or Charlie Three". Due the different English accent, in the beginning the Panama cockpit crews were even confused whether the control staff said "first or third".
Panama ended up missing their actual exit from the runway and continued down the path to exit CO route as KILL was preparing to takeoff from the opposite direction. Neither of the three touch points knew where the other planes are located because Meanwhile in the KILL cockpit, without the official TACT clearance from the control tower, the KILL captain was preparing to take off and began to gain life-off speed down the runway. The last minutes before the crash, communication errors occurred in all three touch points.
The control told the KILL to "stand by for takeoff I will call you when runway is clear", while the KILL captain may only heard "takeoff, runway is clear" through the radio. At the same time, the tower told the Panama "Papa Alpha 1736 report runway clear" which din"t mean the Panama already exited the runway. The last minute transcript is as follows: page | 12 1706:25. 47 APP: Ah-?papa Alpha 1736 report runway clear. 1706:25. 59 parallax: Okay, we'll report when were clear. 1706:31. 69 APP: Thank you. 1706:32. 43 KILL 3: IS he not clear, then? 706:34. 10 KILL 1 : What do you say? 1706:34. 15 parallax: yup. 1706:34. 0 KILL 3: IS he not clear, that pan American? 1706:35. 70 KILL 1: Oh, yes. At the same time the following comments were made in the Pan Am cockpit: 1706:35. 70 Panama: Let's get the # # # [expletive] out of here. There he is--look at him # # # that # # # is coming. 1706:40. 47 Panama: Get off Get off Get off of approaching KILL engines. 1706:50. OOH--almanac. 3 seconds before the collision, the two planes were near each other enough to be visible through the heavy fog.
When the KILL did see the Panama, he tried to force the plane off ground, causing the aircraft"s tail to drag across the runway and caught fire. The Panama also tried to take a sharp turn off the runway into the grass but it was too late for both aircraft. The crash cause huge impact sound and fire explosion, however, accordingly to the Spanish local reporters there were no ground witnesses when the accident occur due to the dense fog. While the Panama cockpit crew and few passengers survived, BACK exploded in midair with no survivors.
From the situation, we can see that communication errors due mainly to the non-standardize aviation language is the cause to this tragedy, especially from the control tower "K" and the KILL cockpit "We"re at takeoff' as well as the decision to take off by KILL Captain Velveteen van Canteen's without confirming the tower. Moreover, if earlier language confusion between Panama and the tower din"t happen, Panama would have exited the runway at CO route and won"t collide into KILL flight at all. 6. Report on the following; Risk Assessment and planning, pre/post crisis.
In the sass, air travel has already developed and taken steps of precautions to prevent disasters form happening. Technical problem analysis, engineering pre-flight checkups and pre-post flight cockpit technical checklists to ensure the safety of the aircraft is up to the standard. However, the risk planning/ crisis planning put less attention on team-work communication and human related errors such as attention errors and perceptive errors. Moreover, in the ass, the captain of the aircraft was giving commands.
Seniority played a big role in the page | 13 cockpit and captains" decision making were not often challenged by the co-pilot or second officers. This series of human related errors contribute to the Teensier accident in 1977. Once the accident took place, it was clear that cockpit and control tower and decision making still have many loopholes that cannot be left unattended. The attention on human error, language barrier and inefficient aviation language became in main focus for international aviation organizations to step in and adjust their approach in these areas for the highest standard of safety.
The post Teensier crisis has marked as one of greatest change in aviation training, crisis preparation and prevention. The improvements are made mainly in the areas of intensive airline staff training. The details are as follows: 1) Crisis Training Anticipate Crises; every pilot and cabin crews are now required to study from the worst case scenarios and earning from experience case-studies. They must complete the international protocol required hours before they received permission to train in the aircraft.
As a result, in training to anticipate the worst that could happen, airline crews are aware and alert of crises during all time of their operation. Communication Training; standardize terminology and codes are taught and the crews must undergo a number of examinations and test before they are qualified to fly. They also studies Communication Patterns, Cue Recognition, Context Facility, and Cultural Intelligence s part of the international standard training as well. Moreover, the language of teamwork is heavily stressed on.
Captains are no longer the seniority figure in the cockpit but work together with the first officer and controller tower for good decision making. "Cross-checking" communication are exercise regularly throughout the industry for the most effective information exchange and reassurance Personality Test and Physical Test; the airline crews are required to take personality test and physical test that would determine whether they would be appropriate for their session to handle mental and physical pressure.
This Crisis training among all staffs keeps the industry and its employees on alert that everyone needs to look out and prepare the unthinkable that can happen. Not only does it Page | 14 helps to stress the importance of safety and the role of each airline staff but also prepare them to react according to the crisis response plan. The case studies also helps the staff to see how even the smallest decision making can create an impact on a large scale. 2) On-Board Crisis Plan Step-by-Step checklist; in the present day, each aircraft and control tower is equipped with checklist that is personalized for every crew position on the aircraft.
The crews must go over the list and crosscheck the items with their copilots, the cabin crews and confirm status with the control tower before the airplane leaves the terminal and taxi to the runway. The crews are also train and given standard procedure to follow when faced with unforeseen emergency. In addition, for the airline stakeholders, in-flight safety demonstration and directions are provided for the passengers. 3) Crisis Drills Once the airline staffs
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