Paper Example on Human and Machine Interface Systems

Every air disaster is different, but at the root of each can be found one or more causes from a grimly familiar list: terrorism, mechanical malfunction, weather, technical trouble, or human error. However, very rarely does a plane wreck result from a combination of all these recurring factors, but that is exactly what happened on the Canary Islands on 27 March 1977 when a perfect storm of catastrophe touched down on Tenerife runway. In the space of an hour, miscommunication, impatience, poor visibility, and technical malfunction culminated in the most deadly aviation disaster in history.

Overview

Gando Airport

The errors, coincidences, and events that resulted in the fatal accident are often too incredible. The story of the terrified accident in aviation begins about four hours before the crash. Two 747s were approaching Gando airport on Grand Canary Islands, KLM 4805 flight from Netherlands, and Pan Am 1736 flight from Los Angeles. The Pan Am plane cabin was nearly full with 378 passengers and 13 flight attendants. Onboard the Dutch aircraft (KLM) was 234 passengers and 14 crew members commanded by KLM chief pilot Captain Jacob Louis Veldhuyzen van Zanten. Van Zanten was the best pilot in the KLM crew, and he managed many departments, he was featured on most of the advertisement about KLM all over the world.

Before the two flights near Las Palmas, an anonymous caller warns that a bomb has been placed at Gando Airport terminal. Although The Canary Islands lie off the coast of Africa, they are Spanish territory; the bomb threats were the work of separatists waging a violent campaign for independence. A few minutes later, a bomb explodes at the airport causing the airport to close abruptly and all flights diverted to Los Rodeos Airport on nearby Tenerife (Smith, 2014).

This diversion proves to be a significant problem; the KLM crew was scheduled to go back to Amsterdam later that day. A long postponement at Tenerife could put them past their responsibilities time limits, which means that if they could not complete the flight they had to overnight the crew and all the passengers in a remote location. Both jumbo jets headed to Tenerife, half an hour away, which had only one runway, a regional airport operating on small airplanes. It was all right to hold a 747 aircraft on a diversion but not a whole fleet of planes as happened on that day, there were not enough places to pack nor were there enough workers since it was Sunday, and the facility was very weak to hold the number of people flooding in.

Tenerife Island

Only two controllers were on duty, and they were not accustomed to handling this much traffic. Pan Am was packed behind three other planes including KLM taking up all the limited spaces and soon all the taxiways were blocked. Thus, the controllers had to find a way in which the airplane will maneuver during takeoff. Unfortunately, the weather began to deteriorate tremendously; the KLM crew started to get worried if they remain on the ground for most of the time they have to go off duty (Documentary Dock, 2017).

Gando airport was reopened, and the KLM crew decided to refuel to save time, instead of taking just enough fuel to take him to his destination, the Dutch captain took on 55 tons enough to get him all the way back to Amsterdam. The controllers were rushing against the weather to make the airport, but the Pan Am flight could not move since it was stuck behind KLM, which was refueling and they had to wait for 30minutes for refueling.

Moments before the Impact

In the meantime, the fog was covering up the runway; visibility dropped from ten kilometers to three in just a few minutes. Pan Am was required to follow KLM along the track then taxi along exists C3, while KLM was supposed to take a 180-degree turn at the end of the runway then back out and go away. The two planes creep along the same track at about 10 miles per hour, and the visibility was fluctuating and went to as low as 500 meters. Pan Am airplane lost sight of the KLM aircraft. With such low profile, the Pan Am had a problem finding the exit they were supposed to turn off, and they were below the minimum take off visibility, the confusion arose from the fact that the third exit C3 required to make a very sharp turn, which would point them in the opposite direction down the taxiway. The next exit C4 had a 45-degree angle seemed to make better sense (CBS News, 2017). Meanwhile, back at the control room for minutes, they had been unable to see either of the jumbos. The control tower asked for Pan Am for their position, and they had not yet found the turn-off. The two flights were just face-to-face a half a mile apart unable to see each other in the fog. KLM was given air traffic control clearance, which is permission to fly the route once airborne but it was not permitted to take off, that had to be obtained separately.

The Crash

KLM accelerated towards the runway at the same moment the Pan Am began to turn off the runway. Six seconds before impact KLM captain noticed that Pan Am was still on the runway, he accelerated at a very high takeoff speed in an attempt to avoid the collision and passed over Pan Am. KLM hit Pan Am at 290km/hr, and it continued flying for another 150metres before slamming into the ground. The 55tons of fuel the Dutch plane had taken created a massive fireball that killed everyone onboard. Only 61 of the Pan Am passengers survived, 583 people died, even today it still the highest death toll of any aviation disaster (Smith, 2014).

Modern economic marketplace exhibits extreme competition and instability. The burden of maintaining a sober working space is laid upon elected leaders who go to extreme extends to prove their competency. Tenerife crash demonstrates that leaders make bad decisions in an attempt to please their employers without considering the effect of their decisions. The need to keep evolving to changing environment is vital to survive the modern market place. However, that is not always the case. Most leaders exhibit extreme control over situations and undermine future leaders who are more open to changes just to maintain their status.

Factors that Hindered Proper Decision-Making

Stress

Stress and its effects on organizational and human behaviors had a huge impact in the Tenerife disaster. In this case, KLM crew was delayed by the terrorist attack at their destination, uncertain and challenging weather and strict flight and duty time limits that were nearing expiration. The Spanish controllers were dealing with a large fleet of planes beyond their control, and they were also working in English a less familiar second language (McCreary, Pollard, Stevenson, & Wilson, 1998).

Taxi-way Congestion

The airport controllers were unfamiliar with the abrupt congestion of the taxi way, that is why they directed Pan Am flight to taxi at exit C3 which was typically impossible for such a large plane. The controllers did not think that that was a problem.

Regression

Regression means that in a stressful situation people behave or act in patterns they learned first. KLM pilot had been an instructor for more than ten years and had flown routes for a short time. This explains the reason why he chose to take off before he was instructed to. The co-pilots and engineer were intimidated by the prestige and seniority of the pilot and therefore regressed to overly subordinate behavior.

Heterodyne

The communication mistakes caused by the two transmissions together (yanxin, 2009), When KLM co-pilot communicated that they were taking off; both the controller and Pan Am pilot simultaneously said something that KLM crew did not hear and could have changed the situation. Pan Am claimed it was still on the runway and the controller telling them to wait until he offers instruction to take off.

Miscommunication

Communication problems were evident in this incident; the co-pilot did not attempt to stop the KLM pilot from illegal takeoff. The Pan Am pilots did not ask for proper instructions from the controller (Chionh, 2014).

Cohesion

The more cohesive a group is, the healthier influence it has on an individual. The KLM pilot had an obligation to take care of his crew, and the crew trusted his judgments due to his vast experience. Thus they choose to maintain group cohesion rather than challenge the captain.

Poor Visibility

Visibility was reduced from 10 kilometers to 300 meters with a few minutes that the two planes were on the runway. Thus they all depended on the radio communication to determine each one's position

Poor Infrastructure

The taxiways were not marked clearly for the Pan Am pilots to spot them in the extreme foggy environment. The airport did not have a radar and lighting on the runway to could have helped the controller to control the planes. Otherwise, the planes could have seen each other

The Pilots Obligations

Both Pan Am and KLM pilots played ignorant of the other party and made decisions that ended up fatally. Some of the obligations are:

Clear Communication

Instead of following the controller's instructions, which he was in doubt of, the Pan Am pilot, should have asked for clearance and negotiated with the controller on the impossibility of the plane taking a turn at C3 or getting the exact instruction on what he meant about the third exist.

The KLM pilot took authority in his hands due to the pressure that was mounting on him without ATC clearance (Documentary Dock, 2017). When the co-pilot or the engineer tried to communicate, he shut them off.

Familiarizing with the Airport

None of the pilots would have thought that such a disaster would have occurred, therefore during the two hours delay, they would have familiarized themselves with the takeoff procedures, and how the airport.

Lessons Learnt

Aircraft support team are highly structured, mechanistic groups known to be capable of breakdown and errors. In the aviation industry, the accident caused by equipment failure amount to only just five percent the rest is primarily human error, and nearly three-quarters of them are caused by human miscommunications (Federal Aviation Administration).

1. In case of technological failure, leaders should find an alternative to the problem.

2. In the aviation industry, the remote control system can act as a third party to help in such instances.

3. Stress management is vital to running a successful organization and imposing strict regulation can leave the crew with little or no option thus some exceptions should be considered.

4. Communication training is essential in any organization to help everyone to communicate efficiently at any level of authority, and bonding events are a great tool to use.

5. Organizations should structure up alternatives in case one fails, such as in case KLM failed to reach their destination on time there would be an alternative that is not so fatal.

Conclusion

None of the KLM crew survived the disaster, which indicates that there are loopholes and questions to be asked. The fact that the best KLM pilot made such a mistake cannot be answered by just investigation; somehow, the blame leans on one side (yanxin, 2009). Leaders should be at the forefront to help their subordinates and listen to them not intimidate them. Humans depend so much on technology on their activities such that in case of changes or failures, decision-making is altered and they become irrational.

References

CBS News. (2017, March 27). Tenerife: Remembering the worlds deadliest aviation disaster. Retrieved Aug 22, 2017, from CBS News: https://www.cbsnews.com/news/tenerife-remembering-the-worlds-deadliest-aviation-disaster/

Chionh, P. (2014, July). Effective Communication. (M. K. Syn, Ed.) Focus(80), pp. 2-17.

Documentary Dock. (2017, Feb 5). Seconds From Disaster - Collision...