The Tenerife Air Disaster, Case Study Example

Introduction

A Case Analysis of The Tenerife Air Disaster will identify three communication problems that existed during the moments leading up the fatal crash, and three remedies that would have prevented it.  A total of 583 lives were cut off due to an accumulation of several factors that surfaced at different times and from relating sources, but were not handled effectively from a communication perspectives, until it was too late. The analysis serve to elucidate specific problem areas using technical literature from different eras, and then offer remedies using selected sections, as well as deductions from the details that was extracted from the communication records of the KLM 747.

Conclusions than will be drawn on the bases of the presentation.

Analysis: Poor Stress Management

In the accident between the two 747’s, error of judgment due to poor stress management control by the Captain of the KLM out of Amsterdam, could be cited as one of the main communication problems that caused the accident to take place.

Stress is often defined as a relation between the person and the environment, and according to Holyrodd and Lazarus (1982), psychological stress requires judgment that environmental and internal demands tax or exceed the individual’s resources for managing them (Holyrodd & Lazarus, 1982).

In the case of the KLM Captain, he and his entire crew were facing fines including imprisonment and loss of licenses from the legal statutes enacted by the Dutch Government and enforceable by his airline, the difficult maneuver that was requested by the control tower, as well as very poor weather which considerable reduce their visibility.

Under Dutch Law, there are prescribe limits as to the number of flying time pilots and their crews could log, before resting and this particular unit time was nearing its end. The present disruption had only exacerbated the problem, and according to Roitsch et al (1982), should they exceed this limit, it could mean imprisonments, and losses of their pilot licenses (Roitsch, Babock and Edmunds, 1982).

In terms of the maneuver demanded by the control tower, 747’s normally require a minimum of 142 feet to make the 180 degree turn, but the Tenerife airfield only had 150 feet available, so it was a challenging exercise that was made worse by the poor weather condition.

It was because Tenerife Airport was 2073 feet above sea level why clouds rather than fog covered the atmosphere, making it impossible for the First Pilot to see the Pan AM 747 3000 feet away  on the other side of the runaway, according to Roitsch et al (1982).

According to Mandler’s theory, autonomic activity (which is often triggered by interruptions) is defined as any event external or internal to the individual, that prevents completion of some action, thought sequences, plan or processing structure, was relevant to both the KLM 747, and the Pan AM crews in some measure.

The series of events starting ,with the bomb threat, the closing of the airport, the diversion to Tenerife,  and the downtime on the tarmac, triggered activities in the pilots’ autonomic nervous systems, and absorbed portions of their information processing capacities. This leads to a decrease in the efficiency in which they (pilots from both 747’s) process complex thoughts (Weick, K. E., 1990).

In the case of the KLM Captain, who had been training pilots for ten years, and had one of his graduate in the cockpit with him, his ability to process complex thoughts was made worse, because he may have thought he was doing simulation exercises when he gives himself the Ok to take off, and did so, causing the planes to collide in mid air.

Remedy

The accident could have been prevented if the Captain and the First Pilot were more communicative about the decisions being made by the former. According to Hage (1980), micro-sociological hypothesis usually require limits, and the human scale is quite smaller than the organizational one (Hage, 1980). In individualism as in the case of the Captain of the KLM deciding on his own to take off, normal curves were dominant, and too much or too little can be either good or bad.

Had they worked as a team, they would have achieved linearity, which according to Hage (1980) lies between both extremes, and helps to enhance performance levels under stress. This perhaps would help them to make the right decision which was to delay the take off until the control tower gave the signal.

According to Wieck (1993), there is a move from individualism to group in terms of communication and decision making; the move is from a micro to a macro, where there are more curvilinear relationships (Wieck, K.E.1983).  McGrath (1971),  informs us that recurrent findings between stress and performance, reveal that individual performance constantly shows up as curvilinear, compare to linear for group measurements (McGrath, 1971).

It is fair therefore to conclude then, that despite the stress the Captain was under, if he had communicated his concerns with his First Officers, the disaster may not have happened, due to the linearity and increase in performance that would have been achieved.

False Hypothesis

The second communication problems that arose during the entire ordeal were that of a False Hypothesis by Captain of the KLM 747, regarding take off from the Tenerife airport base.  Communication according to Wieck (1983) is necessary to detect false hypothesis, and the officers here failed to do so, both in terms of each other as well as with the control tower (Wieck, K.E. 1983).

The crisis had created vertical communication structures, instead of lateral ones, which would have been more ideal for detecting and diagnosing the false hypothesis which was in the Captain’s mind, and caused him to decide to take off on his own approval, as if he was in training school with his students.

According to Wieck (1983), in any crisis situation, there is a high probability that false hypothesis will develop and persist , and they only way it can be detected was by open exchange of messages, independent verification and redundancy in terms of the initial assumptions (Wieck, K. E. 1983).

Davis (1958), gave four situations in which false hypothesis can develop, and they are,

1. High expectancy
2. Using the hypothesis as a form of defense,
3. Following a long period of concentration
4. A diversion of attention

Situations a, b and c could be used to explain the reasons why the Captain of KLM 747 flight developed a false hypothesis while on the tarmac of the Tenerife airport. He perhaps had high expectation of the take off signal that be believed he had received it , and took off as if he had heard it, when in fact it was not given by the control tower.

The situation was also exacerbated by the fact that the Captain being senior officer and teacher of the First Captain did not want to be seen as deficient by his junior, and as a result maintained the false hypothesis as defense for his actions.

Thirdly, the Captain’s mind may well have been focusing on the penalties the Dutch Airlines may hand down to him if he exceeded his limit during this flight.

These situations may have all combined to produce and sustain the false hypothesis that caused the Captain to lift the landing gear and take off from the base on his approval.

Remedy

The situation if this was the only reason for the accident could have been remedied by the leadership of the airline being more proactive and crisis sensitive, by not pairing the Captain and ten year flight instructor with one of his recent graduate.  The disadvantage of this move far outweighs its advantage in times of crises when lives are at stake, especially in this particular case.

The respect the First Officer had for the Captain prevented him from communicating in the manner he should have, when he saw that he was taking off without the approval of the control tower.

According to Helmreich (1984), in a survey conducted between Captains and First Officers, there were significant differences between the responses of Captains who were rated  as outstanding and  those who were in the lower classification, regarding whether or not the lower rank officer should question the decisions of their seniors except in life threatening situations (Helmreich, 1984).

First Officers welcomed the opportunity to question their senior’s decisions, and Captains who were regarded as outstanding, had no problems being questioned by their subordinates, but those who were in the lower categories, resented their authority being questioned outside of life threatening situations (Helmreich, 1984).

Application of the results of this survey to the cockpit organization in the KLM flight 747, would lead one to surmise that the captain of the crew was insecure and full of ego, as well as a pilot of ordinary quality. Whoever evaluated this pilot and have him the top position on the flight made a human resource error, and had it been done differently, perhaps the disaster would not have occurred.

The presence of another First Pilot of a different background on board the KLM 747 flight may have prevented the pilot from developing and maintaining a false hypothesis until the flight took off. This was because he or she would not have the same kind of respect and fear his late counterpart had for the Captain, and would have been more communicative regarding the decision, even to the extent of getting a final take off confirmation from the control tower.

High Salience of Hierarchy and Formal Authority

The third communication problems that could be identified onboard KLM flight 747 was that of high salience of hierarchy and formal authority. The Captain of the crew was also the trainer of the First Officer; therefore a past hierarchical structure had been transferred from the training room to the cockpit, where real life dangers exist and not simulations.

This imposition of varying levels of stress on this situation will have caused interactions among equals according to Wieck (1983), to become more complex, less learned, and more likely to be displaced by hierarchical communication (Wieck, 1983). This kind of communication activates a different mindset as to what is discussed and who initiates it, according to Wieck (1983), and implies that crucial information that could have been shared regarding the decision being taken may have been hindered by the formality of the structure that was in place in the cockpit.

According to Fulk and Mani (1985), communications distortions within hierarchical relationships are similar to subordinate distortion messages used to address message reloads, and Stohl and Redding (1987), reports that these messages include gate keeping, summarization, changing emphasis within a message, and withholding and changing the nature of the information (Stohl, C., Redding, W.C., 1987).

The First Officer at the point of take off was summarizing, gate keeping, and changing emphasis instead of bluntly protesting against the life threatening decision that was being made.

Remedy

A change in the format of the cockpit organizational structure would accommodate greater levels of communication, and by extension, participation in the decision making process that led to the time of departure of the flight. The boundary existing between the Captain and the rest of the flight crew would have been flexible, transparent, and easily removed during crises situations based on the fact that life threatening issues takes precedence over salient hierarchical structures and formal authority.

Errors identified would be discussed and hopefully resolved, rather than contributing to the gradual movements of loosely coupled events to become tightly coupled, which are architects of stress developments within salient hierarchical structures that has formal authority operating (Wieck, 1983).