*Changes the programming*
This year in aviation history, two 747s collide on the ruway at Tenerife's Los Rodeos Airport in the Canary Islands. At 583 casualties, it remains the worst aviation accident in history (the 9/11 attacks are worse, but classified separately in some circles). The 'Swiss cheese' model is often brought up to describe aviation accidents - the more holes there are that line up in each consecutive layer of safety, the higher the risk of an accident. In this case, the 'holes' leading to the Tenerife disaster are listed as follows:
1) Sudden onset of fog, blocking both planes and the control tower from seeing one another (though being solely on instrument flight, or IFR, visibility remained at legal minimums for takeoff)
2) Multiple radio messages in rapid succession, often with some messages "stepped on," meaning two stations attempt to transmit, resulting in neither being able to broadcast
3) Casual use of nonstandard terminology
4) The Pan Am 747 getting lost in the fog and unfamiliar airport layout
5) Los Rodeos ATC operating at higher capacity due to diversions to the airport after a bomb threat at a nearby airport
6) KLM's strict crew hour restrictions, pressuring the crew in what we officially call "get-home-itis"
7) The KLM's flight engineer failing to speak up further after questioning the Captain due to the difference in seniority
8) The KLM 747 opted to refuel while on ground at Los Rodeos, increasing takeoff weight, takeoff distance, and the intensity of the resulting fire
Several things changed about aviation in general following the collision, including standardization of English as the official language of aviation, mandatory readbacks of instructions, and dismantling of cockpit hierarchies in what would ultimately become crew resource management (CRM).
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