Mayday (2013) s16e03 Episode Script

Disaster at Tenerife

NARRATOR: Two jumbo jets.
583 people.
The deadliest air crash of all time.
This was a nightmare beyond all expectation.
If I mess this up I could actually lose my licence.
Blame soon falls on one pilot.
Standby for take-off.
I will call you.
Why would he ignore those instructions? But as investigators sift through all the evidence - We are now at take-off.
- Whoa.
Whoa, whoa.
- What just happened there? - .
.
the disaster in Tenerife grows more and more mysterious.
Why didn't they get off where they were told? These are the top guys.
These are the best in the business.
How could this happen? CONTROLLER: Sunjet 2-8-2, proceed directly to runway, back track and hold.
Los Rodeos Airport on the Spanish island of Tenerife is busier than it's ever been.
BA-783, hold short of the runway and standby for taxi clearance.
The controllers are swamped.
Scandinavian 1-4-2-0, you are cleared for take-off.
Sterling 7-3-9-2, you are next in line.
Sierra Alpha Tango Alpha 69, right turn, heading 0-4-0.
Goodbye.
A few hours ago, dozens of flights were diverted here, after a terrorist bombing shut down a larger airport in nearby Las Palmas.
It's a single runway airport, with a single parallel taxiway, and because of the terrorist event in the region, they had much more traffic than I'm certain that they would normally see.
Sterling 7-3-9-2, taxi to the runway and exit at taxiway Charlie 3.
They were dealing with aircraft that had been delayed for a good part of the day, and now, there was a sense of urgency toget them out and safely on their way.
With so many planes parked on the taxiways, the controllers instruct departing flights to taxi along the airport's only runway, to get into position for take-off.
One of the planes waiting to get to Las Palmas, is Pan Am flight 1736.
We must be getting close.
I sure hope so.
I'm ready for the beach.
NARRATOR: 39-year-old, Robert Bragg, is the first officer.
After we got to Las Palmas, we were supposed to have a day there, and then fly the airplane to Paris and have a day off, and then back to New York.
So, it was supposed to be a very good trip.
His captain is, Victor Grubbs.
Flight engineer, George Warns, completes the highly experienced crew.
Pan American World Airways was not only a pioneer, but they were the one we all looked up to tremendously.
Those of us who wanted to be pilots, and who later were, always had that fantasy that we might some day fly for Pan American.
So, they were the creme de la creme for so many, many decades.
NARRATOR: The Pan Am crew is ready to get back in the air, but they can't taxi to the runway.
A KLM 747, has stopped in front of them to refuel.
We were about 12 feet short of getting around them and we were all on the same radio.
I asked him how long would it be for him to finish fuelling.
He said about 45 minutes.
You're trying to get your passengers where they want to go and now KLM wants more fuel, and it's just one of those things.
It gets frustrating.
These irritations are small, but at the end of a long day they begin to add up.
Not even a sandwich? NARRATOR: It's been a long day for the 378 passengers onboard the Pan Am airplane.
The flight started in Los Angeles, before stopping in New York, and now in Tenerife.
They had been on the airplane 12, 13 hours.
So, they were getting tired.
The passengers have no idea how long the delay will last.
KLM was our big concern.
And hewe found out his fuelling would be finished.
ON RADIO: Tenerife, KLM 4-8-0-5.
We've finished refuelling.
Requesting clearance for start up.
NARRATOR: The KLM aircraft is finally ready to roll.
Both 747s should be back in the air soon.
Clipper 1-7-3-6, requesting start clearance.
I said OK, Pan Am is ready to start also.
Clipper 1-7-3-6, you are cleared to start.
OK.
Pre-start checklist please.
PA: Ladies and gentlemen, the flight deck once again.
I'm happy to say we've been finally cleared to get moving.
We should have you in the air in about 15 minutes from now.
NARRATOR: The Canary Islands, lie off the west coast, of Africa.
Tenerife, is one of seven, in the Spanish archipelago.
The mountainous island is famous for constantly changing weather.
I can't see anything out there.
A fog bank rolled in and visibility went down to almost zero.
Clipper 1-7-3-6, clear taxi into the runway following the 747 from KLM.
Clipper 1-7-3-6.
To expedite the departures of both KLM and Pan Am, they taxied both on the runway at the same time, to put them in a position where they would be ready for a departure.
He said follow KLM down the runway, backtrack, make an exit to get around back of KLM.
So, that's what we were doing.
NARRATOR: Once they get in the air, the flight to Las Palmas should only take about 25 minutes.
KLM 4-8-0-5, how many taxiways did you pass? - I think we just passed Charlie 4 now.
- OK.
NARRATOR: The KLM 747 will be the next plane to take off.
At the end of the runway make 180 and report ready for ATC clearance.
First Officer Bragg is unfamiliar with the airport.
He checks a runway diagram to help find their turning.
OK, that's this one right here.
It goes ahead.
It's gonna put us on the taxiway.
NARRATOR: As they taxi, they listen to the tower controller tell the KLM crew ahead of them, what to do after departure.
ON RADIO: You are cleared to the Papa beacon.
Climb to and maintain flight level nine-zero.
Right turn after take-off.
KLM: Roger.
Cleared to the Papa beacon.
Flight level 9-0.
Right turn atwe are now at take-off.
OK.
Standby for take-off.
I will call you.
And we're still taxiing down the runway, Clipper 1-7-3-6.
Papa Alpha 1-7-3-6, report runway clear.
OK.
We'll report when we're clear.
Thank you.
NARRATOR: The Pan Am crew will be turning off the runway in just a few more yards.
But now something's wrong.
First Officer Bragg can see a plane through the fog.
I think he's moving.
And I looked up and there he was coming down the runway.
It was very obvious that he was moving because his landing lights were shaking.
Look at him.
That idiot's coming! He saw KLM too.
Get off.
Get off! NARRATOR: Captain Grubbs tries to steer clear of the oncoming KLM.
But it's bearing down on them at nearly 200 miles an hour.
He had lifted off the runway.
I could see his rotating beacon underneath.
Get off.
Get off.
Get off.
Get off.
Get off.
Get off! Henry and then I ducked and said a real quick prayer.
God, I hope he misses us.
NARRATOR: The unimaginable collision, between two jumbo jets, has turned a runway in Tenerife, into a disaster zone.
I opened my eyes.
The first thing I noticed, all the windows were gone.
And, it looked like somebody had taken a big knife and just cut the whole top of the airplane off.
Get out! Get out! That's when I decided it was time to leave.
NARRATOR: It's a 45-foot drop onto solid concrete.
And I just jumped right over the side.
I didn't even think about it.
When I hit, I rolled on the ground, and looked around and discovered I wasn't hurt.
Some passengers in the shattered cabin of the Pan Am have also survived.
Get out! NARRATOR: They're desperate to get off the plane.
The airplane was totally burning.
There were flames probably 200 feet high.
An opening in the fuselage offers the possibility of escape, but there are no emergency slides.
The long drop to the runway could be fatal.
With the plane engulfed in flames, it's the only way out.
We're gonna have to jump.
I thought the airplane was gonna blow up.
And I yelled out at them to start jumping.
And they did.
Only 61 people from the Pan Am flight survive.
The cockpit crew is alive, but 335 others are dead.
On the KLM flight, there are no survivors.
248 passengers and crew have been killed.
All told, the disaster claims 583 lives.
It's the deadliest aviation accident of all time.
583 people, with only a few getting out on Pan Am.
This was something that we really had not contemplated when we started building bigger airplanes.
Nobody ever thought, what if we lost two of them in a collision on the ground? This was a nightmare beyond all expectation.
NARRATOR: The next morning, investigators from Spain, The Netherlands, and the United States, are on the scene.
We didn't have a whole lot of experience with 747s crashing at that point.
So, from an accident investigation standpoint, it was gonna be as big a deal as you can get.
Pan Am clearing the runway.
KLM on its take-off roll.
Someone messed up.
They face a huge task, trying to untangle the chain of events that led to this catastrophic runway collision.
The search for the black boxes begins immediately.
The recorders could hold important details about what was happening in both cockpits.
The voice recorders in this case were vital.
You had two airworthy aircraft coming together on the runway.
So the events leading up to that, you know, were key.
It was busy.
Controllers had to get almost 50 off the ground in just a few hours.
Investigators know that Los Rodeos Airport has no ground radar to help controllers track planes.
At a busy location, it's unusual for a controller to have to work without ground radar.
It increases the stress a little bit in the tower.
NARRATOR: There's no question that the small airport, was dealing with more traffic than usual.
Was it too much for controllers to handle? Did they make a fatal mistake? A visit to the tower is the obvious next step.
We've never been that busy.
And OK, well the planes were parked here and here.
They had to use the runway to taxi into position one at a time.
They were actually having to park aircraft on the taxiway, the only taxiway that they had, and therefore kind of deviate from their standard operating procedures.
And, any time you do that unfortunately risk things get a little bit riskier.
So I instructed KLM to taxi to the foot of the runway, make a 180 and wait for take-off clearance.
At the end of the runway, make 180 and report ready for ATC clearance.
And a couple of minutes later he reported that he was in position here.
RADIO: KLM is ready for take-off, waiting for ATC clearance.
When KLM had turned around at the end of the runway and was in position for take-off, we call that line up and wait.
So they are waiting for take-off clearance, which will equal a clear runway.
And then I had Pan Am move up the runway right behind the KLM.
Papa Alpha 1-7-3-6 report runway clear.
- OK.
We'll report when we're clear.
- It's true we were busier than we've ever been before, but we were managing.
We were getting the job done.
NARRATOR: It's becoming clear to investigators that the cause of the Tenerife tragedy goes beyond a busy airport.
Controllers had a lot to do, but they were not overwhelmed.
There must have been other factors at play.
In accident investigation, we learned a long time ago, that there is never ever just one cause and there are a multiplicity of moving parts on this.
I couldn't actually see what happened.
A thick fog had rolled in.
Visibility was almost zero by then.
This particular airport had a unique characteristic, in that it was high enough, so that you would get actually clouds rolling in across the runway.
RADIO: KLM 4-8-0-5, how many taxiways did you pass? The controllers looking out the window could not see any aircraft that were taxiing either on the taxiways or on the runways, and instead had to rely solely on transmissions from the pilots, to report whether or not they were clear of the runway.
NARRATOR: Investigators know that if the controller couldn't see the airplanes through the fog, his instructions to the pilots would have to be crystal clear.
They gather recordings from air traffic control.
Perhaps, the tapes can paint a better picture of what really happened.
That was the key to the whole investigation.
Where were the aircraft on the runways, and what was being said along their path down the runway? Get off.
Get off! Get off! History's deadliest air crash is leading newscasts around the world.
The pressure for answers is not about to let up.
We knew we had a tremendous task on our hands to solve this accident.
Alright.
Let's start with the KLM nearing the end of the runway.
5:02.
NARRATOR: Investigators want to know, if the Tenerife controller, said anything to the KLM or Pan Am pilots that could have led to the collision.
KLM 4-8-0-5, how many taxiways did you pass? They listen to the recordings from inside the tower.
I think we just passed Charlie 4 now.
OK.
Just passed Charlie 4 right here.
NARRATOR: KLM Captain Jacob Van Zanten, and his first officer, Klaas Meurs, taxi up the runway in thick fog.
By the time that the main island airport at Las Palmas reopened, and everybody was getting ready to go, it was down to about 700 or 900 yards visibility, and that's just right at minimums.
RADIO: At the end of the runway, make 180 and report ready - for ATC clearance.
- OK.
KLM was told to proceed to the end of the runway, turn around and wait.
What was the Pan Am flight told to do? Clipper 1-7-3-6, leave the runway 3-1 to your left.
Whoa! What did they just ask him to do? RADIO: I'm sorry.
Say again, please.
Leave the runway, the third one to your left.
OK.
Taxi down the runway, and leave the runway at the first intersection on the left.
Is that correct? Negative.
The third one.
The third one.
Whenever we look at the question of whether or not the air traffic controllers in the tower, the two gentlemen in the tower were giving clear instructions, you've gotta remember we have kind of a linguistic problem here, because these were two Spaniards who speak Spanish as their native language, attempting to speak in aviation English, to an American crew and to a KLM Dutch crew.
He's on an active runway and he doesn't know if he's being told to get off here, here, or maybe here.
There seemed to be some confusion withas to which exit they were supposed to take, and I have a feeling part of that had to do with the accents involved.
Maybe I'll ask him again.
Would you confirm that you want Clipper 1-7-3-6 to turn left at the third intersection? NARRATOR: It takes an extra effort, but the controller eventually makes himself understood.
RADIO: The third one, sir.
One, two, three.
The third one, third! The controller's accent may have been another complicating factor, for pilots, in an unfamiliar airport on a very busy day.
But for investigators, it's not enough to explain the crash.
They need to keep digging.
One, two, three.
This is where they were told to get off, and they clearly understood.
But they moved past C-3.
Why didn't they get off where they were told? The Pan Am plane taxied past the third exit.
Why did it stay on the runway? For more insight, investigators examine the geometry of the turn the Pan Am pilots were asked to make.
That leads to a surprising discovery.
So, you have 148 degree turn here, followed by another one here.
Leaving the runway at the third intersection would have required two very sharp turns, both tighter than 90 degrees.
That's practically impossible.
747 is a beast.
This is a big, big airplane.
You just can't turn it on a dime.
So, a crew is going to always be reluctant, an experienced crew especially like Pan Am's, to take a turn if it doesn't look logical to them.
And this one did not look logical to them.
Alright.
So the collision happened here.
So, he obviously passed C-3 and was headed for C-4.
NARRATOR: Instead of leaving the runway at an exit that required two very difficult turns, the Pan Am crew headed for the fourth exit.
It was further along the runway, but provided a much easier turn.
If you see C-4, it's the only taxiway going off the runway at a 45-degree angle.
The other, C-3, would have not done what we needed to do.
I can see how that would definitely have induced the Pan Am crew to think that Charlie-4 was the exit that they were supposed to turn at.
NARRATOR: In the fog, the KLM crew would not have been able to see that Pan Am 1736, was taxiing past the C3 exit as they waited for take-off instructions from the controller.
KLM is ready for take-off.
Awaiting ATC clearance.
The first clearance they were asking for was a air traffic control route clearance, which tells pilots how to get from the airport that they were at, Tenerife, to their destination airport.
NARRATOR: The air traffic recording suggests the KLM crew knew the correct procedures and was following them.
You are cleared to the Papa beacon, climb to and maintain flight level nine-zero.
Right turn after take-off.
It sounds fine.
Roger.
Cleared to Papa beacon.
Flight level nine-zero.
Right turn out.
We are now at take-off.
OK.
Standby for take-off.
I will call you.
It's kind of verification between the controller and the pilot, that they are doing what they should be doing.
He's telling the tower he's in take-off position, but he's been told to wait for take-off clearance.
So, why does he start his take-off roll? NARRATOR: Investigators are mystified.
Nothing on the tower recording can explain why the KLM crew started down the runway before they were cleared to do so.
The big question then was, you know, once you get over the horrific nature of it and say, "How could this happen?" At the crash site, there's new hope of finding some answers.
Investigators have recovered the black boxes.
The voice recorders were key to the investigation.
That gave us an insight into what was going on in the respective cockpits.
They can only hope the new evidence will be enough to finally solve the mystery of the worst air disaster the world has ever seen.
We've located the CVR.
NARRATOR: The investigation into the Tenerife disaster, shifts to the Washington headquarters, of the National Transportation Safety Board.
Investigator, Dennis Grossi, has painstakingly matched up the cockpit voice recordings with the known movements of both planes.
OK.
Let's listen to the Pan Am.
On this case, fractions of a second mattered.
So, it was important that we had those recorders synched up, so you could hear it and you could have precise measurements of when things were said.
RADIO: Yeah.
That's that 45 there.
That's this one right here.
- The next one is almost a 45.
- Yeah.
Goes ahead.
It's gonna put us on the taxiway.
NARRATOR: The Pan Am cockpit tape confirms that the crew was having a hard time figuring out where to leave the runway.
They're passing C-3 and no-one sees them.
Did the KLM crew think the Pan Am plane was already off the runway? - Keep it going.
- What the tape reveals next - suggests the answer is, no.
- RADIO: We are now at take-off.
And we're still taxiing down the runway, Clipper 1-7-3-6.
NARRATOR: Both crews are using the same radio frequency.
KLM should have heard First Officer Bragg report his location.
That's why I said, we're still on the runway and we will report clear of the runway.
RADIO: Papa Alpha 1-7-3-6, report runway clear.
OK.
We'll report when we're clear.
Thank you.
Crystal clear for all to hear.
He's still on the runway.
Yet KLM continues to take-off.
NARRATOR: Captain Van Zanten, is a highly experienced pilot, with more than 11,000 hours in the air.
What led him to believe the runway ahead was clear, and that he had permission to take off? It just seems so alien for the crew to make that mistake.
I mean this these are the top guys.
These are the best in the business.
He lands just after 13:30.
Investigators turn to the KLM voice recording for answers.
Perhaps, something said in that cockpit, can explain the incomprehensible decision to start down the runway.
We landed here at 1:38.
Yes, I know that but we have to start from 7:00.
That's when we checked in.
You're trying to recreate the cockpit environment, why certain decisions were made, why things were said.
The time limit is 10 hours of flying with an amplitude of 13 hours.
That's with one stopover.
The recording reveals that the captain is worried about work hours.
If the crew exceeds their duty time, they'll be forced to cancel the flight.
And that means probably 30,000 - 40,000 of hotel rooms for the outbound passengers, who they're not gonna be able to carry back that night.
It is a bit of a logistical nightmare, especially in an out station in a foreign place.
NARRATOR: Dutch regulators have also recently tightened the rules governing flight crew duty time.
A Dutch pilot can now have his licence revoked if he exceeds the legal number of hours.
The crew left Amsterdam at 9:00am.
They still have to get their passengers to Las Palmas, pick up another load of passengers, and get back to Amsterdam before the clock runs out.
If I mess this up I could actually lose my licence.
We certainly wouldn't want that.
Well, if we're waiting we might as well refuel.
Tenerife, KLM 4-8-0-5.
Now requesting refuelling at the apron.
Van Zanten's concern over duty time explains why he decided to refuel, while in Tenerife.
He was going to do everything in his power to make sure that he could, you know, complete the flight within his legal duty time limits.
But then, a short time later, the airport in Las Palmas reopens.
To all aircraft, Las Palmas has reopened.
You may ask for start up and clearances at your discretion.
And Van Zanten's plan backfires.
Refuelling takes much longer than expected, and now, he can't move until it's done.
When Las Palmas reopened, here he is sucking on a fuel hose, instead of starting the engines and moving.
This is Clipper 1-7-3-6 requesting start up clearance.
NARRATOR: Van Zanten's decision has a huge impact on the Pan Am flight as well.
The KLM beside you has requested a refuel and it doesn't look like you're going to get by him.
The Pan American 747, they didn't have enough wing tip clearance.
You gotta be kidding me.
Roger Tenerife, Clipper 1-7-3-6.
The other captains were unhappy with him because he was the cork in the bottle.
The refuelling delay means the KLM crew now has only two hours until they're grounded.
Half hour to taxi.
Half hour to get there.
An hour to swap passengers and get back in the air.
It's tight.
And guess what? The weather's getting worse.
RADIO: KLM 4-8-0-5, you are clear to taxi to the runway.
The question facing investigators now, is did the rush to get off the ground in worsening weather, cause the KLM crew to jump the gun? So, he taxis to the end of the runway and does this 180.
We know this from the tower tapes.
Can we hear it from that point please? RADIO: Startinglanding lights on.
Checklist complete.
NARRATOR: Investigators hear more evidence that the captain of KLM flight 4805 may have been in a rush.
- (ENGINES ROAR IN BACKGROUND) - Is he throttling up? Wait a minute.
We do not have ATC clearance.
No, I know that.
Go ahead and ask.
It's obvious that time was an important factor in the KLM Captain's decision-making.
He wasn't gonna waste any time once he got to the end of the runway.
RADIO: KLM is ready for take-off, waiting for ATC clearance.
So, he requests ATC clearance.
We're about a minute from the collision.
When the first officer asked for the clearance he was asking for the air traffic control clearance, completely separate from the clearance to actually roll this 500,000-600,000 pound monster down the runway.
You are cleared to the Papa beacon, climb to and maintain flight level nine-zero.
Right turn after take-off.
NARRATOR: What investigators hear next answers many of the questions plaguing this investigation.
CAPTAIN: Yes! CO-PILOT : Roger.
Clear to the Papa beacon.
Let's go! Check thrust.
Flight level 9-0, right turn out.
We are now at take-off.
- OK.
- "Whoa.
Whoa, whoa.
What just happened there? Play that again please.
NARRATOR: The controller is providing instructions for what to do after take-off You are cleared to the Papa beacon.
Climb to and maintain flight level nine-zero.
- Right turn after take-off.
- Yes! .
.
but the captain reacts as if he's actually been cleared for departure.
They get a clearance from air traffic control that contains the word take-off, and that confirms for them that everything is the way it should be, when in fact everything was not.
Roger.
Cleared to the Papa beacon.
Let's go.
Check thrust.
NARRATOR: Before his first officer has finished reading back the instructions, Captain Van Zanten is already on the roll.
Flight level 9-0.
Right turn out.
We are now at take-off.
NARRATOR: Investigators now know what the Dutch first officer meant by 'at take-off.
' He's reporting that he's actually taking off, not that he's ready to take-off.
Unfortunately, in this case it meant they were taking off from the KLM perspective.
And from the air traffic control perspective, they were hearing we are at take-off position.
NARRATOR: But for investigators there's something about the radio exchange that still doesn't make sense.
According to the tower transcripts, the controller advised him to stay put.
OK.
Standby for take-off.
I will call you.
Why didn't the KLM crew follow that clear instruction to stand by? Give me Pan Am at 17:06.
That's when Pan Am reports on the same frequency that they're still on the runway.
RADIO: And we're still taxiing down the runway, Clipper 1-7-3-6.
Hold it there.
Why would he ignore them? The cockpit recordings continue to baffle investigators, until they hear another critical moment on the KLM tape.
CO-PILOT: We are now at take-off.
OK.
That's what he heard? NARRATOR: It's a stunning discovery.
Flight level 9-0.
Right turn out.
We're now at take-off.
RADIO: OK.
(RADIO STATIC) The two warnings to stay put were never heard in the KLM cockpit.
The tower and the Pan Am flight both made their critical calls at the exact same moment.
OK.
And we're still taxiing down the runway.
Standby for take-off.
I will call you.
Clipper 1-7-3-6.
The simultaneous transmissions produced a four second squeal in the KLM cockpit.
We are now at take-off.
- OK.
- (OVERLAPPING VOICES) NARRATOR: The crew heard only one word - OK.
Unfortunately, this happened during that pause after the controller says, OK.
For KLM, they had no opportunity to hear the controller saying standby for take-off, nor were they able to hear, because they were speaking at the same time, the Pan Am crew reporting that they were still on the runway.
So, what's next? NARRATOR: There's one final transmission recorded in the KLM cockpit.
RADIO: Papa Alpha 1-7-3-6, report runway clear.
It should have alerted the crew that another plane - was still on the runway.
- OK.
We'll report when we're clear.
Thank you.
Only the flight engineer seems to have understood it.
He's not clear then? What did you say? Is he not clear then, the Pan American? Oh, yes.
NARRATOR: The pilots ignore his concern and miss their last chance to avoid a disaster that will claim 583 lives.
Oh, dammit! (SUSPENSEFUL MUSIC PLAYS) Van Zanten should not have moved without explicit clearance.
You learn that in probably the first or second lesson in aviation.
Do not take off unless you get a clearance.
Investigators dig into the career of Captain Van Zanten.
They're looking for anything that might explain why an experienced pilot would violate such a fundamental rule.
This guy was a superstar.
They learn that, Van Zanten, was one of KLM's top pilots.
He was the face of the airline, the director of flight safety, and head of the flight training department.
How could a human being with so much intelligence, so much capability, and experience and position and the director of safety, how could he fail like this? NARRATOR: Investigators suspect that in an odd twist, the captain's elevated status, may have played a role in the Tenerife disaster.
Back in those times, everyone had an awe of the captain, if you will.
His word was god.
His word was unquestioned.
If he has that kind of authority it's less likely for someone his junior, in this case the flight engineer and the first officer, to challenge anything he does.
OK.
We'll report when we're clear.
Thank you.
- Is he not clear then? - What did you say? Is he not clear then, the Pan American? Oh, yes.
The conversation in the KLM cockpit leading up to the accident seems to support that notion.
But Van Zanten's esteemed status doesn't explain the most troubling question of all.
Why did he believe it was safe to take off in the first place? Logically, you should make extra clear that, "Hey, we're taking off.
Is the runway clear?" Investigators search desperately for an answer, and come across a stunning detail in the captain's flight log.
It could be the final piece of the puzzle.
This was his first flight in three months.
Records show that Van Zanten's cockpit hours had dropped dramatically in recent years.
He was spending most of his time in a simulator, training other pilots.
The simulation is interesting because when you spend a lot of time as an instructor in a simulator, it's an artificial environment that we try to make as real as possible.
OK.
Checklist complete.
Let's go.
Thrust.
NARRATOR: Flight simulators do a remarkably good job at recreating the experience of a real flight.
But there is one very important element missing.
There is no air traffic controller in a simulator.
His focus was on training, and there was this difference in the way you treat air traffic control communications in the training environment versus the real world.
OK, let's go.
Thrust.
V-1.
Here we go.
Take-off thrust.
- Rotate.
- OK let's go.
Take-off thrust.
Thrust.
Let's go.
All that time he spent in a simulator works against him.
RADIO: Climb to and maintain flight level nine-zero.
Right turn after take-off.
- Roger.
Cleared to the Papa beacon.
- Let's go.
Check thrust.
Jacob Van Zanten's attempt to take-off without a clearance, resulted from his time in the simulator, and that he kind of reset himself.
He was his own clearance authority in the simulator.
And then two separate radio calls that should have told him the Pan Am was off the runway cancel each other out.
- OK.
- (OVERLAPPING VOICES) NARRATOR: The world's deadliest airline accident is now all but inevitable.
I think he's moving.
Look at him.
That idiot's coming! Basically, we had a captain who wanted to get off the ground as rapidly as possible.
Oh, dammit! The weather was not cooperating, and he was about out of crew duty time, and in a situation like that the human mind, our carbon-based brains tend to jump a few cogs, so to speak.
Get off.
Get off.
Get off.
Get off! Get off! Get off!! He had a gun cocked and loaded by various factors and he was the one that pulled the trigger.
But you have to take them all in connection.
NARRATOR: The investigation into the collision at Tenerife, results in dozens of recommendations.
Few aviation accidents have triggered a greater number of significant changes.
That's what began to be the seed of training, for what we later called crew resource management, where we said to the captain, "We're onto you, bub.
" "You're a human being.
You can make mistakes, even when you have no intention to and even when you're completely qualified.
" NARRATOR: KLM and other airlines transform their training methods for captains, helping them become more responsive to their crewmates.
Even the most senior and the most highly trained individuals can make mistakes and we need to rely on the resources of all the crewmembers to compensate for that.
You are cleared to the Papa beacon.
Climb to and maintain flight level nine-zero.
Right turn after take-off.
The accident also changes the very language used by controllers around the world.
Controllers don't use the word take-off unless they actually mean and intend for the aircraft to be doing just that, taking off.
Instead, they will substitute the word, after departure, turn right heading zero-four-zero or something to that effect.
Those 583 people, those, those people did not die in vain.
We have learned those lessons.
They changed the whole face of aviation safety.