A tragic story about the consequences of bad decisions
The Captain of KLM Flight 4805 had to be irritated. His plane, carrying 235 passengers and 14 crew members, had taken off from Amsterdam’s Schiphol Airport at 0900 hours (local time) en route to Gando Airport in Las Palmas, Canary Islands (part of Spain).[1] But six hours later, as the plane neared Las Palmas, the pilot, Jacob Van Zanten, was given bad news by the Gando Airport air traffic controller.[2]
VAN ZANTEN: “Gando, KLM four eight zero five is with you now.”
GANDO AIRPORT CONTROLLER: “KLM four eight zero five, Gando. The airport is closed.”
KLM Boeing 747 “Rhine.” Photo by clipperarctic, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
Most of the passengers on KLM Boeing 747, named “Rhine” by the airline, a charter flight for Holland International Travel Group, were on their way to meet cruise ships.[3] But then a bomb placed by separatists exploded in the flower shop in the passenger terminal building.[4] Due to the threat of a second explosion, the terminal building was evacuated and the airport closed. Planes scheduled to land at Las Palmas Airport were diverted to Los Rodeos Airport on Tenerife Island, half an hour away.[5] It was the closest alternative that could handle a 747.[6]
Let’s observe here that the conjunction of a terrorist bombing and the pending landing of the KLM flight was the first unforeseen occurrence in the story we are unfolding.
The problems of diversion
Captain Van Zanten’s irritation was likely fed by the knowledge that this diversion could prove to be a significant problem. He and his KLM crew were scheduled to return to Amsterdam later that day; a long delay at Tenerife could put them past their duty time limit, the time at which they are required to get 12 hours of rest before they can go back on duty.[7] If that were the case, the passengers would not get to their destination that day nor would the crew get home. All would have to be accommodated on Tenerife, if overnight accommodations could even be found, at sizeable expense to KLM. And the 747 would not be available to fly other routes.[8]
One might think that a pilot would not be so sensitive to the expense of a diversion, but Captain Van Zanten was no ordinary pilot. He was the top pilot in KLM’s management. He was the head of safety and KLM’s chief flight instructor, with 11,700 flight hours, of which 1,545 hours were on the 747.[9] Van Zanten was an individual whom everyone at that airline looked up to. He was the public symbol for KLM pilots: his face was on KLM’s advertising around the world. Indeed, KLM’s inflight magazine that month featured him in an ad headlined, “KLM. From the people who make punctuality possible.”[10] Van Zanten spent most of his time training other pilots, including the co-pilot who was in the next seat, Klaas Meurs. In fact, Van Zanten issued Meurs his 747 flight certification.[11]
KLM magazine ad featuring Captain Jacob Van Zanten.
Our second observation about this story is that it involves one of the world’s best pilots and a delay, the potential negative consequences of which he may not be able to avoid despite his flight experience and senior stature at the airline.
In the meantime, Pan American Flight 1736, flying with a fresh crew of 18 and 378 passengers from New York’s JFK Airport to Las Palmas, also got the bad news.[12]
FIRST OFFICER ROBERT BRAGG: “Gando, Pan Am one seven three six. Good afternoon.”
GANDO AIRPORT AIR TRAFFIC CONTROLLER: “Pan Am one seven three six, Gando. The airport is closed.”[13]
Pan Am Boeing 747 “Clipper Victor.”
Pan Am called its airplanes “Clippers” and named this plane “Clipper Victor.” It also was a Boeing 747, but no ordinary one: It was the first 747 in service. It made the first commercial 747 passenger flight, New York to London, in January 1970. In another quirk of history, later that year the plane was hijacked to Cuba.[14]
Now, seven years later, on March 27, 1977, Captain Victor Grubbs and First Officer Bragg had to unexpectedly divert their plane to Tenerife. Not surprisingly, the already weary crew and passengers, who had been traveling for 12 hours since take-off in New York, were not happy about the change.[15]
Mt. Teide, Tenerife, Canary Islands.
The new destination airport for both 747s was situated next to Spain’s highest mountain, Mt. Teide, and was prone to fog and mist, often at short notice.[16] [17] On this day fog was around and about the airport’s one runway, the major taxiway parallel to it and the four short taxiways connecting the two.[18]
“A traffic jam”
Normally sleepy, Los Rodeos on this day was packed with diverted flights.[19] After the KLM 747 landed, its passengers were deplaned to wait out the delay. The Pan Am 747 landed 30 minutes later and was parked next to the KLM 747. First Officer Bragg later reported, “The ground situation was a traffic jam, because, when we landed there, the ramp was so crowded with other airplanes, and we were directed to taxi down to the end of the ramp area and park behind three other airplanes,” including the KLM 747.[20] The Pan Am passengers could not be deplaned because the terminal building was overflowing with passengers from the other waiting planes.
In the meantime, the KLM crew worried that the limit on their hours on duty in the cockpit could make it impossible to fly to Las Palmas and then complete the return flight to Amsterdam that same day. There would be no possibility of flying after 8 pm: The Dutch aviation authority had introduced stricter flight time limits, a violation of which could result in a fine, loss of license, or even prison.[21]
While the KLM 747 had enough fuel on board to reach Las Palmas airport, Captain Van Zanten decided to take on 55 more tons of fuel while waiting at Los Rodeos, to enable an immediate return from Las Palmas after unloading passengers rather than then waiting to refuel there.[22] The crew and KLM operations had calculated that the fully fueled KLM 4805 could make the return trip to Amsterdam just within their flight operations limit.[23] But a tradeoff was that the amount of speed necessary to lift the 747 off the runway and the takeoff distance were increased by the extra fuel weight.[24]
Old control tower at Los Rodeos Airport on Tenerife. Photo by Aisano, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
The two controllers on duty had been listening to a soccer game on the radio while 11 aircraft waited on the ground.[25] At around four o’clock, Las Palmas reopened and began accepting traffic. The controllers discussed how to maneuver the planes for takeoff.[26] Given the airport congestion and because the part of the main taxiway near the terminal was too narrow for a 747, they decided that the first 747 would taxi onto the runway, taxi to the opposite end, turn around and take off, a common maneuver called “back taxiing.”[27] The second 747 would taxi on the runway until about midfield, then take a left turn on a short taxiway and then a right turn onto the main parallel taxiway, and take that to the end of the runway. The upshot was that their plan had both aircraft begin taxiing on the runway.
A 747 parked on the apron at Los Rodeos airport.
The Rhine and Clipper Victor sat adjacent to one other, parked at the southeast corner of the apron, their wingtips almost touching.[28] The loaded Pan Am 747 was ready to depart, but its access to the runway was blocked by the KLM 747 and a refueling vehicle. First Officer Bragg remembered, “The engineer and I went out underneath the right wing and, basically, stepped off the distance between our wingtip and the KLM 747's wingtip, and we were 12 feet short of being able to taxi easily around the airplane.”[29]
Schematic showing the KLM 747 blocking the Pan Am 747 on the apron leading to the runway. Diagram by Jussi Pajau, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
The refueling took about 35 minutes. After that, the KLM passengers were brought back to the plane. A search for a missing Dutch family of four delayed the flight even longer. One passenger who lived on Tenerife chose not to reboard for Las Palmas. The Los Rodeos runway coordinator later recalled, “Boarding was very complicated, because, when the passengers were called for their flights, they were scattered throughout the airport, in the cafeteria or buying souvenirs. We had to go round them up.”[30]
So now added to the factors in this saga are an overwhelmed airport, a plane that’s ready to go but blocked from moving, further delay and a 747 that will take off weighted down by full fuel tanks.
Then the weather got worse.
The fog rolled in
During the delay for refueling the KLM 747, low-lying clouds descended and enveloped the airport. Runway visibility that had been 10 kilometers quickly diminished to 3 kilometers.[31] Captain Van Zanten’s impatience over the possibility of the airport closing because of weather was evident: He urged his crew members, “Hurry, or else it will close again completely.”[32]
After the KLM pilots started their plane’s engines, First Officer Klaus Meurs had a confusing conversation with the ground controller who spoke poor English, Fernando Azcunaga.
MEURS: “We require back track on one two for take-off runway three zero.”
CONTROLLER: “OK, four eight zero five…taxi…to the holding position runway three zero taxi into the runway and – ah – leave runway third to your left.”
MEURS: “Roger sir, entering the runway at this time and the first taxiway we, we get off the runway again for the beginning of runway three zero.”
CONTROLLER: “OK, KLM eight zero – ah – correction, four eight zero five taxi straight ahead – ah – for the runway and – ah – make – ah – a back track.”
MEURS: “Roger, make a back track.”
A few seconds passed.
MEURS: “KLM four eight zero five is now on the runway.”
CONTROLLER: “Four eight zero five roger.”
MEURS: “Approach, you want us to turn left at Charlie one, taxiway Charlie one?”
CONTROLLER: “Negative, negative, taxi straight ahead – ah – up to the end of the runway and make back track.”
MEURS: “OK, sir.”[33]
Note that we have added to the story a confused first officer, a confused controller whose English is not the best, and fog descending. The situation will only get worse.
With the KLM 747 taxiing, the Pan Am 747 got underway.
FIRST OFFICER ROBERT BRAGG: “Pan Am one seven three six ready to start.”
CONTROLLER: “Pan Am one seven three six clear to taxi on runway, following the KLM.”
BRAGG: “Pan Am one seven three six following KLM.”[34]
Meanwhile, the KLM First Officer inquired about the runway centerlights not being lit and was told by the controller that they were out of service.[35] The controller then passed this information on to the Pan Am crew. Captain Grubbs noted in the Pan Am cockpit, “We need 800 meters if you don't have that centerline.” He meant that greater visibility (which other evidence suggests was actually 700 meters) was required for takeoff with centerline lights off. This situation would require extra attention from both crews to assure that their aircraft were aligned properly on the runway.[36]
In a matter of minutes, the KLM 747 had reached the end of the runway and was ready to execute the tricky 180-degree turn that would line it up for takeoff going back down the runway.[37]
Exit confusion
At this time the Pan Am 747 was out on the runway, taxiing slowly, following the KLM 747. First Officer Bragg recollects, “We saw the fog bank come off of the right hill, and proceed down and stop right on the runway. So our visibility went from unlimited to 500 meters. We lost sight of the KLM airplane.”[38] The pressure on the crew to get their 747 off the runway increased. Like the confusion earlier involving KLM 4805’s instructions, similar confusion arose regarding Pan Am 1736’s instructions for exiting the runway.
BRAGG: “Ah – we were instructed to contact you and also to taxi down the runway, is that correct?”
CONTROLLER: “Affirmative, taxi into the runway and – uh – leave the runway third, third to your left.”
BRAGG: “Third to left, OK.”[39]
Cockpit recordings would show that as they taxied along at 10 miles an hour the concerned crew debated whether the controller had said that they should turn off at the third or the first left taxiway.
BRAGG: “Would you confirm that you want the Clipper one seven three six to turn left at the t-h-i-r-d intersection?”
CONTROLLER: “The third one, sir, one, two, three, third, third one.”[40]
Then after more cockpit conversation about the proper taxiway, the controller instructed the crew to report when they were leaving the runway. The plane continued to taxi. Because of the fog the crew was confused about which taxiway was the third one. Some of the confusion arose because the third exit, Charlie 3, required a making a nearly impossible sharp turn that would point the plane in the wrong direction down the taxiway.[41] Using the next exit, Charlie 4, with a 45-degree angle, seemed to make more sense. Bragg later explained, “We couldn't see any taxiways. We couldn't see...barely, the centerline of the runway we were taxiing on, but we knew that the 45-degree angle to the left was the taxiway to take.”[42]
Continuing to the next taxiway would not normally be a problem, but this kept Clipper Victor on the runway for several more seconds.
Back in the control tower, the controllers were understandably tense because they could not see either 747 on the runway and needed to be sure of their precise locations.
CONTROLLER: “Pan Am one seven three six, approach. Position please.”
BRAGG: “One seven three six, just checking that.”
The Pan Am crew was still trying to find the turnoff.[43]
Could this situation get even dicier? We have added to the story more confusion in plane-controller communications, no centerline lights, even worse visibility and a crew who could not find its runway exit.
At this time, the KLM 747 made its 180-degree turn. It was just after 5 p.m. The two 747s were now face-to-face a half a mile apart, unable to see each other in the fog.
Cleared for takeoff…or not?
With the plunging visibility, KLM Captain Van Zanten had to have been more worried than ever that the airport would close and the crew and passengers would have spend the night on Tenerife. HIs irritability had been noted by the controllers and other pilots. But suddenly the fog lessened. The captain remarked that visibility had improved to the 700 meters required for take-off. First Officer Meurs interjected that they did not yet have air traffic control (ATC) clearance for take-off. Van Zanten asked Meurs to get clearance.[44]
MEURS: “Uh, the KLM…four eight zero five is now ready for take off…uh and we’re waiting for our ATC clearance.”
The controller responded not with take-off clearance, but with routing clearance that had not yet been relayed to the plane because of the complex situation that the controllers and the crews were dealing with.
CONTROLLER: “KLM eight seven zero five uh you are cleared to the Papa Beacon climb to and maintain flight level nine zero right turn after take-off proceed with heading zero four zero until intercepting the three two five radial from Las Palmas VOR.”[45]
Meurs repeated the routing clearance instructions back to the controller, and then somewhat hesitantly added over the noise of accelerating engines a phrase not normally used in aircraft operations: “…and we are now, uh, at takeoff.” The KLM 747 crew appeared to have thought the route clearance also included takeoff clearance.[46]
CONTROLLER: “OK…stand by for takeoff, I will call you.”[47]
Except that all that was heard in the KLM cockpit was “….K” followed by a shrill 3.74 second noise, radio interference because at the very same time the Pan Am first officer was radioing the tower saying “And we are still taxiing down the runway, the Clipper one seven three six…” The Pan Am transmission was also blocked by the interference and thus the KLM crew did not hear that Pan Am 1736 was still taxiing directly ahead them.[48]
The tower was concerned about the location of the Pan Am 747.
CONTROLLER: “Roger alpha one seven three six report the runway clear.”
BRAGG: “OK, we’ll report when we’re clear.”
CONTROLLER: “Thank you.”[49]
We now see our story coming to a head with the KLM captain determined to get into the air, engines revving up, confusion about take-off clearance and the other 747 still on the runway.
Tragically, Rhine had already started on its take-off run down the runway, heading straight for Clipper Victor.
The Pan AM 747 was set to turn off the runway at taxiway 4 when the KLM was rolling toward it. Diagram by Xerkes2K, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
“We’re going!”
Having interpreted the route clearance as take-off clearance, Captain Van Zanten said to his crew, “We’re going!” First Officer Meurs was concentrating on the takeoff. The "Okay" from the tower had come over the radio with seeming clarity, and with that it seemed reasonable to conclude that they were cleared for take-off.[50]
A computer graphics simulation of the Rhine accelerating in the fog toward Clipper Victor. Graphic by Anynobody, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
Nonetheless, KLM Flight Engineer Willem Schreuder sounded concerned.[51] The 747 was gaining speed and entering another of the clouds that had been blowing across the runway. He could see nothing ahead. What did the Pan Am crew mean by their message: "We'll report when clear"? They were already clear, weren't they? How could Captain Van Zanten start the takeoff if not? Schreuder asked the captain, “Is he not clear then?” Captain Van Zanten responded in a clipped manner, “What do you say?” The flight engineer asked again, “Is he not clear, that Pan American?” to which the captain responded emphatically, “Oh, yes.”[52]
The KLM 747 was now rolling at 80 knots and accelerating.
Schreuder stopped talking, likely thinking, “The captain must be right.”[53]
The KLM 747 continued to pick up speed. Emerging from the band of fog, it became visible to the Pan Am crew just as they were beginning their turn onto the fourth taxiway.[54]
Diagram of how the aircraft wound up on a collision course.
In the Pan Am cockpit, Captain Grubbs exclaimed, “Damn, that son of a bitch is coming right at us!”
In the KLM cockpit, Captain Van Zanten realized that he was on a collision course. He tried to take off early. There was no hope in stopping Rhine in time to avoid the collision or swerving off the runway.[55] The only possibility was to fly over the top of the Pan Am 747. The KLM captain yanked the control column as far back as it would go. The plane reared up in the air. “Damn! Come on! Come on! Come on! Come on!” he yelled. In the other plane, First Officer Bragg likewise yelled, “Get off! Get off!”[56]
Graphic of the collision of the two 747s at Los Rodeos Airport. Graphic by SafetyCard, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
With the weight of its full fuel load, the KLM 747’s tail struck the runway and scraped 65-feet of concrete until it finally became airborne.[57] But it was still too low. Its main landing gear was ripped away as it sheared off the top of Pan Am 1736’s fuselage.
The KLM 747 returned to the runway at less than 100 knots, skidded and burst into flames. The inferno consumed all 234 passengers and 14 crew members.[58]
Remains of the burnt out KLM 747 Rhine.
Some passengers and crew members were able to jump from the collapsing Pan Am 747’s burning airframe. But 335 were killed in the collision or burned to death.[59]
Of the 644 people aboard the two 747s, 583 were killed and only 61 survived.[60] This was the worst accident in aviation history.
Monument by the Dutch artist Rudi van de Wint erected on Tenerife in memory of the 583 victims of the Los Rodeos Airport disaster. The spiral at the top suggests the spiral stairway up to a 747’s upper deck. Photo by Jesús Manuel Pérez Triana, licensed under the Creative Commons Attribution-Share Alike 2.0 Generic license.
Why did Tenerife happen?
The massive investigation of and subsequent reports on the Tenerife airport disaster offer deep insight into what happened and what went wrong. As a result, aviation authorities and airlines worldwide changed procedures.
The “what” of the disaster, in retrospect, is obvious, including fog, no centerline lights, language and radio transmission problems, airport overcrowding, delays, a fuel-heavy aircraft and more. But they are insufficient to explain why the KLM 747 collided with the Pan Am 747.
Explaining the “why” of the disaster leads us to our great concern, bad decisions and what to do to avoid them when making a good decision is imperative for a mission-critical outcome.
The “why” questions
Asking “why” with an understanding that people are not perfectly rational beings raises questions about the human factors that led to:
- An airport being sited in a place with a prevalence of bad weather.
- A ground controller whose English was poor.
- Controllers listening to a soccer game while on duty.
- Controllers allowing flight operations – indeed, multiple planes – on a runway covered with fog and without centerlights.
- Controllers issuing confusing instructions.
- Controllers directing the Pan Am aircraft to a taxiway with a sharp turn nearly impossible for the plane to execute.
- Controllers not taking more care to assure safe operations in a chaotic situation.
- The Pan Am crew’s seeming lack of haste in exiting the runway.
- The Pan Am crew’s continuing uncertainty about the correct runway exit taxiway.
- Controllers not stopping the KLM 747 when it was clear the Pan Am 747 was lost.
- The time pressure on the KLM crew.
- KLM’s head pilot seemingly putting economics ahead of safety.
- That expert pilot adding the risk of taking off with a full fuel load.
- Crew members interpreting route clearance also as takeoff clearance.
- The KLM pilot starting takeoff without clear authorization to do so.
- That pilot ignoring the concerns of his crew mates.
- Crew members who were unclear if takeoff authorization had been issued and worried that the Pan Am flight could still be on the runway but not pressing the point with their captain.
- The overall lack of attention to the whole situation rather than immediate details.
My upcoming book, tentatively titled Big Decisions: Why we make decisions that matter so poorly. How we can make them better, will offer answers to most of these questions, through a deep exploration of mental biases, traps, flaws and shortcuts that lead to bad decisions.
At this juncture, just listing the traps and biases that likely enmeshed the actors in the Tenerife disaster gives us a startling sense of the extent to which we are subject to mental traps and biases, most often without any conscious awareness. The many pitfalls that can betray us underscore how important it is for us to dig deeper to understand why we make bad decisions and learn what we can do to make better decisions when it really counts. Without such understanding, the risk of disasters, perhaps lesser but maybe even the equivalent of Tenerife or even greater, will continue to loom in our personal and organizational lives.
Six categories of mental traps and biases
In research for Big Decisions, I have unearthed hundreds of mental traps and biases that skew decision making and, for better understanding, have catalogued them in six major categories:
Psychological. “Processing problems” – Errors occurring as a result of our cognitive biases and mental shortcuts that can lead to systematic deviations from logic, probability or rational choice.
Perception. “Input problems” – Effects and errors in the organization, identification, and interpretation of sensory information that we use to represent and understand the environment around us.
Memory. “Storage and recall problems” – Errors from the process in which information is encoded, stored and retrieved from our brain.
Logical. “Reasoning problems” – Errors arising from making fallacious arguments that are deductively invalid or inductively weak or that contain an unjustified premise or ignore relevant evidence.
Physiological. “Limbic system problems” – Mental processing and judgment shortfalls caused by physical factors that affect the function of our brain, such as arousal, depression and fatigue.
Social. “Interpersonal problems” – Biases and errors stemming from how we view and interact with the people around us, with causes including social categorization, in-group favoritism, prejudice, discrimination and stereotyping.
How the Tenerife actors were swayed
In the Tenerife disaster, initial analysis suggests that the individuals with a role in the horrible outcome were enmeshed by as many as 68 mental traps and biases, in all categories.
The “why” factors that were likely at work that led to the Tenerife airport disaster included at least 36 psychological biases and traps:
- Action-oriented bias
- Availability heuristic
- Backfire effect
- Bad news avoidance
- Bald man fallacy
- Bayesian conservatism
- Cognitive dissonance avoidance
- Commitment heuristic
- Confirmation bias
- Emotion
- Epistemic arrogance
- Escalation of commitment
- Familiarity heuristic
- Hyperbolic discounting
- Illusion of control
- Impulsivity
- Isolated problem trap
- Loss avoidance
- Narrow framing
- Normalcy bias
- Observer effects
- Optimism bias
- Overconfidence effect
- Power
- Primacy effects
- Priming effects
- Probability neglect
- Regret aversion
- Restraint bias
- Risk blindness
- Risk compensation
- Selective perception
- Semmelweis reflex
- Serial position effects
- Single-effect trap
- Subjective validation
The “why” factors also likely included at least six perception traps and biases:
- Change blindness
- Contrast effect
- Fundamental cognitive error
- Inattention blindness
- Platonicity error
- Salience biases
Three memory traps may also help explain the “why” of the Tenerife disaster:
- Conservatism or regressive bias
- Illusion of truth effect
- Suggestibility
The “why” factors also likely involved at least eight logic traps and biases:
- Black Swan blindness
- Certainty bias
- Conjunction fallacy
- Hasty generalization
- Irrational escalation
- Jumping to conclusions
- Narrative fallacy
- Rule-based decisions
In addition, very likely at work to explain the “why” of the disaster were four physiological effects:
- Decision fatigue
- High stress
- Sleep deprivation
- Stimulated limbic system
Lastly, the “why” of the Tenerife airport disaster likely can also be attributed to at least 11 social traps and biases:
- Availability cascade
- Bandwagon effect
- False consensus effect
- Group think
- Halo effect
- Illusion of explanatory depth
- Projection bias
- Reactance
- Reciprocation
- Shared information bias
- Sunflower management
How we make decisions matters
This telling of the Tenerife disaster story will anchor the introduction of Big Decisions. It serves as an attention-getting account showing why we ought to give great thought to our decision-making process and how to make the big decisions better.
The chapters of Big Decisions that will follow will explore the origins of our mental traps, biases and shortcuts (“Smartphones on the Savannah”), our inability to make rational, optimal decision amidst undecidability and unknowability (“The madness of not knowing”), what leads us to irrational decisions (“Like a lost shepherd, we lead ourselves astray”), and how so many specific traps, biases, errors and shortcuts plague our decision making.
Then Big Decisions will reveal decision-making best practices discovered through research, examine what constitutes a big decision and how to recognize when one is needed, and give examples of some really good decisions. Finally, I will offer an evidence-based process built on best practices that, hopefully, we can consciously use when the necessity for a big decision confronts us or our organization.
Throughout Big Decisions, I will tell many more stories about individuals and organizations whose decision making went off the rails and led to detrimental and even ruinous results. These real-world cases teem with examples of the pernicious effects of mental traps, biases, errors and shortcuts on decision making. Subjects for the stories I intend to tell and analyze include:
- Bank of America – Countrywide
- Bernie Madoff
- Brian Cullinan
- Brutus
- Cuban Missile Crisis
- Custer
- Donald Trump
- FedEx
- Firestone
- Flight 370
- The French Panama Canal
- Fukushima
- Galileo
- Gettysburg
- Google
- The Great Powers before World War I
- Henry Ford
- Hillary Clinton
- Kodak
- Lehman Brothers
- Marissa Meyer
- NASA
- Rob Hall
- Samsung
- Uber
- The U.S. Panama Canal
- Volkswagen
- Wells Fargo
- Yahoo
Throughout Big Decisions, as the exploration of bad decision making and what to do about it proceeds, I will unfold yet another story. Even compared with Tenerife aircraft disaster, this story scales up the actors and the consequences of bad decisions. You will have to wait for the book to read about and learn from this saga of incredibly bad decision making and ensuring personal and societal damage.
Note: All images are believed to be in the public domain unless otherwise indicated.
Endnotes
[1] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration. http://lessonslearned.faa.gov/ll_main.cfm?TabID=1&LLID=52&LLTypeID=2
[2] “The Deadliest Plane Crash," (https://www.pbs.org/wgbh/nova/transcripts/3315_planecra.html), NOVA, PBS, October 17, 2006. http://www.pbs.org/wgbh/nova/space/deadliest-plane-crash.html
[3] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017 http://www.telegraph.co.uk/travel/comment/tenerife-airport-disaster/
[4] Chris Kilroy, “Special Report: Tenerife,” AirDisaster.com, October 18, 2007. https://web.archive.org/web/20071018035500/http://www.airdisaster.com/special/special-pa1736.shtml
[5] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration.
[6] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[7] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[8] ALPA Study Group, "Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 9. https://www.webcitation.org/5zRT8z0Rm?url=http://www.project-tenerife.com/engels/PDF/alpa.pdf P. 14.
[9] ALPA Study Group, "Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 4.
[10] Kathleen Bangs, “Calamity and Coincidence: 40 Years Later Are We at Risk of Another Tenerife?” disciplesofflight.com, March 29. 2017 https://disciplesofflight.com/remembering-tenerife-airport-disaster/
[11] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[12] “Accident description,” Aviation Safety Network, Flight Safety Foundation. https://aviation-safety.net/database/record.php?id=19770327-1
[13] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[14] “Clipper Victor, 27 March 1977,” This Day in Aviation, March 27, 2017. https://www.thisdayinaviation.com/tag/clipper-victor/
[15] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[16] ALPA Study Group, "Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 8
[17] “Tenerife 1977 – Why 747 Service to Las Palmas?” Airliners.net, July 29, 2015. http://www.airliners.net/forum/viewtopic.php?t=593183&start=50
[18] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[19] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[20] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[21] Jan U. Hagen, “KLM Flight 4805: The burden of speaking up,” EMST Knowledge. https://knowledge.esmt.org/sites/default/files/11_hagen_book-klm-flight-4805-final-neu.pdf
[22] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[23] ALPA Study Group, "Human Factors Report on the Tenerife Accident,” Air Line Pilots Association, 7.
[24] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[25] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[26] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[27] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource. https://www.theairlinepilots.com/forumarchive/flightsafety/klmpanamdisaster.php
[28] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[29] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[30] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[31] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[32] Jan U. Hagen, “KLM Flight 4805: The burden of speaking up,” EMST Knowledge.
[33] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 40. http://www.project-tenerife.com/engels/PDF/Tenerife.pdf
[34] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[35] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 41.
[36] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration.
[37] Kathleen Bangs, “Calamity and Coincidence: 40 Years Later Are We at Risk of Another Tenerife?” disciplesofflight.com, March 29. 2017
[38] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[39] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 49.
[40] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 51.
[41] “Lessons Learned from Civil Aviation Accidents: KLM Flight 4805 collision with Pan Am Flight 1736 at Tenerife,” Federal Aviation Administration.
[42] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[43] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[44] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 47.
[45] “27 March 1977 - KLM 4805 & PanAm 1736,” Cockpit Voice Recorder Database. https://www.tailstrike.com/270377.htm
[46] Patrick Smith, “The true story behind the deadliest air disaster of all time,” The Telegraph, March 27, 2017
[47] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 57.
[48] “Accident description,” Aviation Safety Network, Flight Safety Foundation.
[49] “27 March 1977 - KLM 4805 & PanAm 1736,” Cockpit Voice Recorder Database.
[50] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[51] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[52] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 45.
[53] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[54] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[55] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[56] “The Deadliest Plane Crash," NOVA, PBS, October 17, 2006.
[57] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 26.
[58] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[59] “KLM Pan Am Disaster,” PIA CRM Islamabad, The Airline Pilots Resource.
[60] “Report on the accident involving aircraft BOEING 747 PH-BUF of KLM and BOEING 747 N 736 PA of PANAM: Joint Report KLM – PAA,” December 7, 1978, 5.